Healthcare Provider Details

I. General information

NPI: 1063781862
Provider Name (Legal Business Name): GALVA FAMILY DENTISTRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 MARKET ST
GALVA IL
61434-1766
US

IV. Provider business mailing address

217 MARKET ST
GALVA IL
61434-1766
US

V. Phone/Fax

Practice location:
  • Phone: 309-932-2000
  • Fax: 309-932-8904
Mailing address:
  • Phone: 309-932-2000
  • Fax: 309-932-8904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019028309
License Number StateIL

VIII. Authorized Official

Name: SCOTT BIALOBRESKI
Title or Position: OWNER
Credential: D.D.S.
Phone: 309-932-2000