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General NPI Number Information
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NPI Number | 1285067298
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Entity Type | Organization
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Legal Business Name | KATY DENTAL, INC.
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Dates
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Enumeration Date | 08/13/2013
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Last Update Date | 08/13/2013
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Provider Practice Location Address
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Address Line | 3510 HOBSON RD SUITE 302
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City | WOODRIDGE
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State | IL
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Zip | 60517-1439
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Country | US
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Telephone | 630-971-3626
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Fax | 630-971-3752
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Provider Business Mailing Address
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Address Line | 3510 HOBSON RD SUITE 302
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City | WOODRIDGE
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State | IL
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Zip | 60517-1439
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Country | US
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Telephone | 630-971-3626
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Fax | 630-971-3752
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARTHA CATALINA VILLASENOR
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Credential | D.D.S.
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Telephone | 708-601-5081
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 019024012
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License Number State | IL
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