Provider Demographics
NPI:1417327750
Name:VILLAGE DENTAL, PC
Entity Type:Organization
Organization Name:VILLAGE DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WATERLOO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-251-8990
Mailing Address - Street 1:523 PARK DR
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60043-1082
Mailing Address - Country:US
Mailing Address - Phone:847-251-8990
Mailing Address - Fax:847-853-0781
Practice Address - Street 1:523 PARK DR
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:IL
Practice Address - Zip Code:60043-1082
Practice Address - Country:US
Practice Address - Phone:847-251-8990
Practice Address - Fax:847-853-0781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190228771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty