Healthcare Provider Details

I. General information

NPI: 1346264850
Provider Name (Legal Business Name): PRINCETON DENTAL CARE, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 E PERU ST
PRINCETON IL
61356-2199
US

IV. Provider business mailing address

PO BOX 547 440 EAST PERU STREET
PRINCETON IL
61356-0547
US

V. Phone/Fax

Practice location:
  • Phone: 815-879-5273
  • Fax:
Mailing address:
  • Phone: 815-879-5273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number019023357
License Number StateIL

VIII. Authorized Official

Name: DR. PEDRO J. MONZON
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 815-879-5273