# CRYSTAL LAKE PEDIATRIC DENTAL LTD.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1043311681
- **Authorized official:** DR. ANTHONY LOUIS MINUTILLO DDS,MSD (PRESIDENT)
- **Authorized official phone:** (815) 356-7960

## Contact information

- **Practice address:** 820 E TERRA COTTA AVE, 111, CRYSTAL LAKE, IL 60014-3649
- **Practice address phone:** (815) 356-7960
- **Practice address fax:** (815) 356-8051
- **Mailing address:** 820 E TERRA COTTA AVE, 111, CRYSTAL LAKE, IL 60014-3649
- **Mailing address phone:** (815) 356-7960
- **Mailing address fax:** (815) 356-8051

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | — | IL | Yes |

## Other

- **Enumeration date:** 09/26/2006
- **Last updated:** 08/22/2020