Provider Demographics
NPI:1376532119
Name:VILLAMONTE, MAMERTO S II (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAMERTO
Middle Name:S
Last Name:VILLAMONTE
Suffix:II
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 1:7234 W NORTH AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-4239
Mailing Address - Country:US
Mailing Address - Phone:708-583-1557
Mailing Address - Fax:
Practice Address - Street 1:7234 W NORTH AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-4239
Practice Address - Country:US
Practice Address - Phone:708-583-1557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2007-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004705Medicaid