Provider Demographics
NPI:1083868806
Name:JULIA R. PESAVENTO, D.M.D.
Entity Type:Organization
Organization Name:JULIA R. PESAVENTO, D.M.D.
Other - Org Name:KATHERINE F. STEWART, D.D.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:REGINA
Authorized Official - Last Name:PESAVENTO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-395-1711
Mailing Address - Street 1:1075 FEATHERSTONE RD
Mailing Address - Street 2:SUITE 30
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5906
Mailing Address - Country:US
Mailing Address - Phone:815-395-1711
Mailing Address - Fax:815-395-1705
Practice Address - Street 1:1075 FEATHERSTONE RD
Practice Address - Street 2:SUITE 30
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
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JULIA R. PESAVENTO, D.M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty