Provider Demographics
NPI:1700034089
Name:VILLALTA, LEONOR CECILIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEONOR
Middle Name:CECILIA
Last Name:VILLALTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2547 W SPRINGFIELD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2821
Mailing Address - Country:US
Mailing Address - Phone:217-722-4565
Mailing Address - Fax:
Practice Address - Street 1:2547 W SPRINGFIELD AVE APT 2
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2821
Practice Address - Country:US
Practice Address - Phone:217-552-8503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57582122300000X
IL019029681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist