Provider Demographics
NPI:1669094041
Name:CHERRYVALE DENTAL CENTER LLC
Entity type:Organization
Organization Name:CHERRYVALE DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BART
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-332-3477
Mailing Address - Street 1:1957 PAWLISCH DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112-1067
Mailing Address - Country:US
Mailing Address - Phone:815-332-3477
Mailing Address - Fax:815-332-3470
Practice Address - Street 1:1957 PAWLISCH DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1067
Practice Address - Country:US
Practice Address - Phone:815-332-3477
Practice Address - Fax:815-332-3470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental