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General NPI Number Information
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NPI Number | 1528454030
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Entity Type | Organization
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Legal Business Name | AV DENTAL OF WOODRIDGE
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Dates
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Enumeration Date | 04/10/2015
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Last Update Date | 04/10/2015
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Provider Practice Location Address
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Address Line | 7546 JANES AVE
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City | WOODRIDGE
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State | IL
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Zip | 60517-2926
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Country | US
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Telephone | 630-985-9787
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Fax |
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Provider Business Mailing Address
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Address Line | 7546 JANES AVE
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City | WOODRIDGE
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State | IL
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Zip | 60517-2926
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Country | US
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Telephone | 630-985-9787
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | JONATHAN VILLANUEVA
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Credential |
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Telephone | 630-324-6750
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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 | 019029734
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License Number State | IL
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