Provider Demographics
NPI:1891477352
Name:LIBERTYVILLE ORAL SURGERY PC
Entity Type:Organization
Organization Name:LIBERTYVILLE ORAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-367-8656
Mailing Address - Street 1:1236 AMERICAN WAY
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3936
Mailing Address - Country:US
Mailing Address - Phone:847-367-8656
Mailing Address - Fax:
Practice Address - Street 1:1236 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3936
Practice Address - Country:US
Practice Address - Phone:847-367-8656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTYVILLE ORAL SURGERY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty