Provider Demographics
NPI:1285067298
Name:KATY DENTAL, INC.
Entity type:Organization
Organization Name:KATY DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:CATALINA
Authorized Official - Last Name:VILLASENOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-601-5081
Mailing Address - Street 1:3510 HOBSON RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1439
Mailing Address - Country:US
Mailing Address - Phone:630-971-3626
Mailing Address - Fax:630-971-3752
Practice Address - Street 1:3510 HOBSON RD
Practice Address - Street 2:SUITE 302
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1439
Practice Address - Country:US
Practice Address - Phone:630-971-3626
Practice Address - Fax:630-971-3752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024012302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019024012Medicaid