Provider Demographics
NPI:1356489801
Name:VILLALOBOS, ERNESTO ANTONIO (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:ANTONIO
Last Name:VILLALOBOS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 ANITA LN
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-2306
Mailing Address - Country:US
Mailing Address - Phone:815-875-3032
Mailing Address - Fax:
Practice Address - Street 1:1318 MERIDEN ST
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-1030
Practice Address - Country:US
Practice Address - Phone:815-539-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2013-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0260981223G0001X
WADE000094921223G0001X
MI29010182331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9177123Medicaid