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General NPI Number Information
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NPI Number | 1417327750
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Entity Type | Organization
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Legal Business Name | VILLAGE DENTAL, PC
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Dates
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Enumeration Date | 09/29/2015
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Last Update Date | 09/29/2015
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Provider Practice Location Address
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Address Line | 523 PARK DR
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City | KENILWORTH
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State | IL
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Zip | 60043-1082
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Country | US
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Telephone | 847-251-8990
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Fax | 847-853-0781
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Provider Business Mailing Address
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Address Line | 523 PARK DR
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City | KENILWORTH
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State | IL
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Zip | 60043-1082
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Country | US
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Telephone | 847-251-8990
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Fax | 847-853-0781
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Authorized Official
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Title or Position | OWNER
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Name | DR. CATHY S WATERLOO
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Credential | DDS
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Telephone | 847-251-8990
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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 | 019022877
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License Number State | IL
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