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NPI Code Detail

MEDICARE: JOSE VILLA DDS PC

MEDICARE: JOSE VILLA DDS PC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice Dentistry019021973IL

General Provider Information

NPI Number : 1053706481
Entity Type Code : Organization
Provider Name (Legal Business Name) : JOSE VILLA DDS PC
Provider Business Mailing Address
First Line : 2841 GRAND AVE
Second Line :
City : WAUKEGAN
State : IL
Zip : 60085-2372
Country : US
Telephone Number : 847-360-1610
Fax Number : 847-360-1689
Provider Business Practice Location Address
First Line : 2841 GRAND AVE
Second Line :
City : WAUKEGAN
State : IL
Zip : 60085-2372
Country : US
Telephone Number : 847-360-1610
Fax Number : 847-360-1689
Authorized Official
Title or Position : GENERALIST/ASSISTANT BOOKKEEPER
Name : MS. BRUSELA F. VILLA
Credential :
Telephone Number : 773-458-4443
Provider Enumeration Date : 04/02/2015
Last Update Date : 04/02/2015

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