Provider Demographics
NPI:1447644802
Name:INNOVATIVE PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:INNOVATIVE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVACCA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-848-2010
Mailing Address - Street 1:55 S MAIN ST STE 241
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-5377
Mailing Address - Country:US
Mailing Address - Phone:630-848-2010
Mailing Address - Fax:630-848-2011
Practice Address - Street 1:55 S MAIN ST STE 241
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-5377
Practice Address - Country:US
Practice Address - Phone:630-848-2010
Practice Address - Fax:630-848-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL47442961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty