Provider Demographics
NPI:1609942994
Name:VILLA, JOSE (DDS)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:VILLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:OMAR
Other - Middle Name:
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1426 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2111
Mailing Address - Country:US
Mailing Address - Phone:773-528-0068
Mailing Address - Fax:773-528-0088
Practice Address - Street 1:1426 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2111
Practice Address - Country:US
Practice Address - Phone:773-528-0068
Practice Address - Fax:773-528-0088
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20190219731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363914276OtherDENTAL