Provider Demographics
NPI:1063570752
Name:PRAIRIE VIEW DENTAL LLC
Entity type:Organization
Organization Name:PRAIRIE VIEW DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOZWIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-895-6100
Mailing Address - Street 1:115 W PEACE RD
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178
Mailing Address - Country:US
Mailing Address - Phone:815-895-6100
Mailing Address - Fax:815-895-6107
Practice Address - Street 1:115 W PEACE RD
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-895-6100
Practice Address - Fax:815-895-6107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty