Provider Demographics
NPI:1407031305
Name:ILLINOIS VALLEY ENDODONTICS LLC
Entity type:Organization
Organization Name:ILLINOIS VALLEY ENDODONTICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CERESA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-224-3636
Mailing Address - Street 1:1601 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-3507
Mailing Address - Country:US
Mailing Address - Phone:815-224-3636
Mailing Address - Fax:815-220-1479
Practice Address - Street 1:1601 4TH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-3507
Practice Address - Country:US
Practice Address - Phone:815-224-3636
Practice Address - Fax:815-220-1479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty