Provider Demographics
NPI:1245334978
Name:VERBAN, EMIL M JR (DDS)
Entity type:Individual
Prefix:MR
First Name:EMIL
Middle Name:M
Last Name:VERBAN
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:EMIL
Other - Middle Name:M
Other - Last Name:VERBAN
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DDS PC
Mailing Address - Street 1:2103 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701
Mailing Address - Country:US
Mailing Address - Phone:305-662-8448
Mailing Address - Fax:509-662-7617
Practice Address - Street 1:2103 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701
Practice Address - Country:US
Practice Address - Phone:305-662-8448
Practice Address - Fax:509-662-7617
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13193122300000X
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist