Healthcare Provider Details

I. General information

NPI: 1790998748
Provider Name (Legal Business Name): DENTAL DESIGN GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E OGDEN AVE
NAPERVILLE IL
60563-8616
US

IV. Provider business mailing address

1000 E OGDEN AVE
NAPERVILLE IL
60563-8616
US

V. Phone/Fax

Practice location:
  • Phone: 630-355-9010
  • Fax: 630-355-9926
Mailing address:
  • Phone: 630-355-9010
  • Fax: 630-355-9926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-022779
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-025099
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021-002028
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021-001200
License Number StateIL

VIII. Authorized Official

Name: MR. JONATHAN VILLANUEVA
Title or Position: MANAGER
Credential:
Phone: 630-355-9010