Provider Demographics
NPI:1518330505
Name:GALVA FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:GALVA FAMILY DENTISTRY, INC.
Other - Org Name:PORT BYRON FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:BIALOBRESKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-932-2000
Mailing Address - Street 1:308 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61275-9038
Mailing Address - Country:US
Mailing Address - Phone:309-523-3325
Mailing Address - Fax:
Practice Address - Street 1:308 11TH ST
Practice Address - Street 2:
Practice Address - City:PORT BYRON
Practice Address - State:IL
Practice Address - Zip Code:61275-9038
Practice Address - Country:US
Practice Address - Phone:309-523-3325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GALVA FAMILY DENTISTRY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190305151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty