Healthcare Provider Details

I. General information

NPI: 1912424672
Provider Name (Legal Business Name): CICERO FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N PERU ST
CICERO IN
46034-9498
US

IV. Provider business mailing address

522 E JASPER ST
PARIS IL
61944-2437
US

V. Phone/Fax

Practice location:
  • Phone: 317-984-3531
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: BLAKE WESTRA
Title or Position: OWNER
Credential: DMD
Phone: 217-549-6928