Provider Demographics
NPI:1467177030
Name:BOCA DENTAL STUDIO
Entity Type:Organization
Organization Name:BOCA DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-668-3876
Mailing Address - Street 1:205 S PEORIA ST APT 1327
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3114
Mailing Address - Country:US
Mailing Address - Phone:847-668-3876
Mailing Address - Fax:
Practice Address - Street 1:1 E DELAWARE PL STE 110
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1449
Practice Address - Country:US
Practice Address - Phone:847-668-3876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-06
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1811424450OtherNPPES