Provider Demographics
NPI:1043435175
Name:PESAVENTO, JULIA R (DMD)
Entity Type:Individual
Prefix:DR
First Name:JULIA
Middle Name:R
Last Name:PESAVENTO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 FEATHERSTONE ROAD, SUITE 30
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61072
Mailing Address - Country:US
Mailing Address - Phone:815-395-1711
Mailing Address - Fax:815-395-1705
Practice Address - Street 1:1075 FEATHERSTONE RD STE 30
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5906
Practice Address - Country:US
Practice Address - Phone:815-395-1711
Practice Address - Fax:815-395-1705
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0196561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$OtherSOCIAL SECURTIY NUMBER
IL019-019656OtherLICENSE NUMBER