Healthcare Provider Details

I. General information

NPI: 1396132890
Provider Name (Legal Business Name): ZAVALA DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4939 W 14TH ST
CICERO IL
60804-1419
US

IV. Provider business mailing address

4939 W 14TH ST
CICERO IL
60804-1419
US

V. Phone/Fax

Practice location:
  • Phone: 708-652-1080
  • Fax:
Mailing address:
  • Phone: 708-652-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019027256
License Number StateIL

VIII. Authorized Official

Name: DR. JESSE ZAVALA
Title or Position: DENTIST
Credential: DDS
Phone: 815-534-0563