Provider Demographics
NPI:1831606433
Name:GALVA FAMILY DENTISTRY, INC
Entity type:Organization
Organization Name:GALVA FAMILY DENTISTRY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-932-2000
Mailing Address - Street 1:217 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:GALVA
Mailing Address - State:IL
Mailing Address - Zip Code:61434-1766
Mailing Address - Country:US
Mailing Address - Phone:309-932-2000
Mailing Address - Fax:
Practice Address - Street 1:114 W STRATFORD DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-7301
Practice Address - Country:US
Practice Address - Phone:309-682-6459
Practice Address - Fax:309-682-7036
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GALVA FAMILY DENTISTRY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190164531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty