Provider Demographics
NPI:1477906345
Name:HERMANSON, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:HERMANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 E RIVERSIDE BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4804
Mailing Address - Country:US
Mailing Address - Phone:815-877-4300
Mailing Address - Fax:
Practice Address - Street 1:2028 E RIVERSIDE BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4804
Practice Address - Country:US
Practice Address - Phone:815-877-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0308351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019.030835OtherDENTIST