Provider Demographics
NPI:1720074206
Name:WILWERT, MONICA M (DDS)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:M
Last Name:WILWERT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ROCK FALLS
Mailing Address - State:IL
Mailing Address - Zip Code:61071-1005
Mailing Address - Country:US
Mailing Address - Phone:815-626-2230
Mailing Address - Fax:
Practice Address - Street 1:1300 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ROCK FALLS
Practice Address - State:IL
Practice Address - Zip Code:61071-1005
Practice Address - Country:US
Practice Address - Phone:815-626-2230
Practice Address - Fax:815-626-6339
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4358122300000X
IA082101223G0001X
IL0190266521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID4358OtherSTATE OF IDAHO LICENSE
IA08210OtherIA STATE LICENSE
IL019026652OtherIL STATE LICENSE
IL01922652OtherIL STATE LICENSE
IA1418608OtherCONTROLLED SUBSTANCE#