Provider Demographics
NPI:1770605164
Name:WILLENBORG, STEPHEN (DMD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:WILLENBORG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 PEMBROKE CT
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-3168
Mailing Address - Country:US
Mailing Address - Phone:217-342-4374
Mailing Address - Fax:
Practice Address - Street 1:610 N KELLER DR
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1814
Practice Address - Country:US
Practice Address - Phone:217-347-7021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice