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General NPI Number Information
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NPI Number | 1013151901
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Entity Type | Organization
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Legal Business Name | LAGRANGE DENTAL MANAGEMENT
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Dates
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Enumeration Date | 04/23/2009
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Last Update Date | 04/23/2009
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Provider Practice Location Address
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Address Line | 342 SHERWOOD RD
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City | LA GRANGE PARK
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State | IL
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Zip | 60526-1967
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Country | US
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Telephone | 708-482-4610
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Fax | 708-482-0246
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Provider Business Mailing Address
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Address Line | 342 SHERWOOD RD
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City | LA GRANGE PARK
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State | IL
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Zip | 60526-1967
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Country | US
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Telephone | 708-482-4610
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Fax | 708-482-0246
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MR. JONATHAN VILLANUEVA
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Credential |
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Telephone | 630-324-6749
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019022779
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License Number State | IL
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