Provider Demographics
NPI:1043311681
Name:CRYSTAL LAKE PEDIATRIC DENTAL LTD.
Entity Type:Organization
Organization Name:CRYSTAL LAKE PEDIATRIC DENTAL LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:MINUTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MSD
Authorized Official - Phone:815-356-7960
Mailing Address - Street 1:820 E TERRA COTTA AVE
Mailing Address - Street 2:111
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3649
Mailing Address - Country:US
Mailing Address - Phone:815-356-7960
Mailing Address - Fax:815-356-8051
Practice Address - Street 1:820 E TERRA COTTA AVE
Practice Address - Street 2:111
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3649
Practice Address - Country:US
Practice Address - Phone:815-356-7960
Practice Address - Fax:815-356-8051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty