Provider Demographics
NPI:1922242817
Name:BRIDGEVIEW DENTAL MANAGEMENT
Entity Type:Organization
Organization Name:BRIDGEVIEW DENTAL MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-324-6749
Mailing Address - Street 1:8729 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-1905
Mailing Address - Country:US
Mailing Address - Phone:708-529-2200
Mailing Address - Fax:708-974-3685
Practice Address - Street 1:8729 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455-1905
Practice Address - Country:US
Practice Address - Phone:708-529-2200
Practice Address - Fax:708-974-3685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190227791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty