Provider Demographics
NPI:1912424672
Name:CICERO FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:CICERO FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTRA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-549-6928
Mailing Address - Street 1:522 E JASPER ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944-2437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 N PERU ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IN
Practice Address - Zip Code:46034-9498
Practice Address - Country:US
Practice Address - Phone:317-984-3531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty