Provider Demographics
NPI:1053706481
Name:JOSE VILLA DDS PC
Entity type:Organization
Organization Name:JOSE VILLA DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERALIST/ASSISTANT BOOKKEEPER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRUSELA
Authorized Official - Middle Name:F
Authorized Official - Last Name:VILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-458-4443
Mailing Address - Street 1:2841 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2372
Mailing Address - Country:US
Mailing Address - Phone:847-360-1610
Mailing Address - Fax:847-360-1689
Practice Address - Street 1:2841 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2372
Practice Address - Country:US
Practice Address - Phone:847-360-1610
Practice Address - Fax:847-360-1689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190219731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty