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General NPI Number Information
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NPI Number | 1447644802
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Entity Type | Organization
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Legal Business Name | INNOVATIVE PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 03/24/2015
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Last Update Date | 03/24/2015
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Provider Practice Location Address
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Address Line | 55 S MAIN ST STE 241
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City | NAPERVILLE
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State | IL
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Zip | 60540-5377
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Country | US
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Telephone | 630-848-2010
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Fax | 630-848-2011
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Provider Business Mailing Address
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Address Line | 55 S MAIN ST STE 241
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City | NAPERVILLE
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State | IL
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Zip | 60540-5377
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Country | US
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Telephone | 630-848-2010
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Fax | 630-848-2011
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ANTHONY LAVACCA
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Credential | DMD
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Telephone | 630-848-2010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 4744296
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License Number State | IL
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