Provider Demographics
NPI:1245431246
Name:AVILA, VICTORIANO (DDS)
Entity Type:Individual
Prefix:DR
First Name:VICTORIANO
Middle Name:
Last Name:AVILA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 N SEDGWICK ST
Mailing Address - Street 2:APARTMENT #3R
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5328
Mailing Address - Country:US
Mailing Address - Phone:312-404-4041
Mailing Address - Fax:
Practice Address - Street 1:9906 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-3207
Practice Address - Country:US
Practice Address - Phone:562-803-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103140122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist