Provider Demographics
NPI:1982446050
Name:CAVENDER, MICHAELA RENEE (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAELA
Middle Name:RENEE
Last Name:CAVENDER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4961 N GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-5372
Mailing Address - Country:US
Mailing Address - Phone:630-589-2683
Mailing Address - Fax:
Practice Address - Street 1:210 N 4TH ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:IL
Practice Address - Zip Code:61523-2058
Practice Address - Country:US
Practice Address - Phone:309-274-3820
Practice Address - Fax:866-309-7302
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190351741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice