Provider Demographics
NPI:1760977078
Name:PEBBLEWOOD DENTAL
Entity Type:Organization
Organization Name:PEBBLEWOOD DENTAL
Other - Org Name:PEBBLEWOOD DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAVARRO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-369-6222
Mailing Address - Street 1:1550 N ROUTE 59 STE 148
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-0152
Mailing Address - Country:US
Mailing Address - Phone:630-369-6222
Mailing Address - Fax:
Practice Address - Street 1:1550 N ROUTE 59 STE 148
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-0152
Practice Address - Country:US
Practice Address - Phone:630-369-6222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026759122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty