Provider Demographics
NPI:1235595331
Name:AVILA DENTAL PC
Entity Type:Organization
Organization Name:AVILA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIANO
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-404-4041
Mailing Address - Street 1:6144 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4628
Mailing Address - Country:US
Mailing Address - Phone:773-585-8000
Mailing Address - Fax:773-585-8001
Practice Address - Street 1:6144 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4628
Practice Address - Country:US
Practice Address - Phone:773-585-8000
Practice Address - Fax:773-585-8001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BERWYN DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty