Healthcare Provider Details

I. General information

NPI: 1013098045
Provider Name (Legal Business Name): CATHERINE E. CAVANAUGH D.D.S,, M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 W WEAVER RD
FORSYTH IL
62535-9764
US

IV. Provider business mailing address

714 STEVENS CREEK BLVD
FORSYTH IL
62535-9741
US

V. Phone/Fax

Practice location:
  • Phone: 217-872-0623
  • Fax: 217-872-0525
Mailing address:
  • Phone: 217-875-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12014549A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number019023172
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: