Provider Demographics
NPI:1528400371
Name:ERNESTO A VILLALOBOS, DDS, MS, LLC
Entity Type:Organization
Organization Name:ERNESTO A VILLALOBOS, DDS, MS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:A
Authorized Official - Last Name:VILLALOBOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:815-875-3032
Mailing Address - Street 1:672 ANITA LN
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-2306
Mailing Address - Country:US
Mailing Address - Phone:815-875-3032
Mailing Address - Fax:
Practice Address - Street 1:1318 MERIDEN ST
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-1030
Practice Address - Country:US
Practice Address - Phone:815-539-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-22
Last Update Date:2013-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026098122300000X
MI2901018233122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9177123Medicaid