Provider Demographics
NPI:1417137217
Name:VAKILI, REZA (DDS)
Entity Type:Individual
Prefix:MR
First Name:REZA
Middle Name:
Last Name:VAKILI
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 1:4450 N. PROSPECT RD.
Mailing Address - Street 2:SUITE S5
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616
Mailing Address - Country:US
Mailing Address - Phone:309-839-2586
Mailing Address - Fax:309-839-2542
Practice Address - Street 1:4450 N. PROSPECT RD
Practice Address - Street 2:SUITE S5
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616
Practice Address - Country:US
Practice Address - Phone:309-839-2586
Practice Address - Fax:309-839-2542
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025774122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist