Healthcare Provider Details

I. General information

NPI: 1417137217
Provider Name (Legal Business Name): REZA VAKILI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7013 N STALWORTH DR
PEORIA IL
61615-9465
US

IV. Provider business mailing address

7013 N STALWORTH DR
PEORIA IL
61615-9465
US

V. Phone/Fax

Practice location:
  • Phone: 309-839-2586
  • Fax: 309-839-2542
Mailing address:
  • Phone: 309-839-2586
  • Fax: 309-839-2542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019025774
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: