| Organization Name: | CRYSTAL LAKE PEDIATRIC DENTAL LTD. |
| NPI Number: | 1043311681 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ANTHONY LOUIS MINUTILLO (PRESIDENT) |
| Mailing Address: | 820 E Terra Cotta Ave 111 Crystal Lake |
| State: | IL US |
| Postal Code: | 600143649 |
| Phone Number: | 8153567960 |
| Fax Number: | 8153568051 |
| NPI Enumeration Date: | 09/26/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223P0221X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | Pediatric Dentistry |
| Taxonomy Definition: | An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. |