Provider Demographics
NPI:1225910607
Name:32 COTTAGE DENTAL LLC
Entity type:Organization
Organization Name:32 COTTAGE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-828-1463
Mailing Address - Street 1:2206 COTTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1447
Mailing Address - Country:US
Mailing Address - Phone:309-828-1463
Mailing Address - Fax:
Practice Address - Street 1:2206 COTTAGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-1447
Practice Address - Country:US
Practice Address - Phone:309-828-1463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty