=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346264850
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRINCETON DENTAL CARE, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 04/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 E PERU ST
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61356-2199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-879-5273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 547 440 EAST PERU STREET
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61356-0547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-879-5273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PEDRO J. MONZON
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 815-879-5273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 019023357
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------