Healthcare Provider Details

I. General information

NPI: 1578324083
Provider Name (Legal Business Name): DR LAYER DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 S NATOMA AVE
WORTH IL
60482-1930
US

IV. Provider business mailing address

4508 BLACKHAWK LN
LISLE IL
60532-1560
US

V. Phone/Fax

Practice location:
  • Phone: 319-671-1233
  • Fax:
Mailing address:
  • Phone: 319-671-1233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. THERON GLENN LAYER
Title or Position: PRESIDENT
Credential: DDS
Phone: 319-671-1233