1356556146 NPI number — RIVERSIDE DENTAL MANAGEMENT, INC

Table of content: (NPI 1356556146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356556146 NPI number — RIVERSIDE DENTAL MANAGEMENT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE DENTAL MANAGEMENT, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DENTURE SERVICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356556146
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7716 W. 26TH ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH RIVERSIDE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60546-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-447-2266
Provider Business Mailing Address Fax Number:
708-447-2486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7716 W. 26TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH RIVERSIDE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60546-1509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-447-2266
Provider Business Practice Location Address Fax Number:
708-447-2486
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VILLANUEVA
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
630-324-6749

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  019022779 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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