Healthcare Provider Details

I. General information

NPI: 1114448578
Provider Name (Legal Business Name): JACQUELINE MAGALLANES DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7124 W DIVERSEY AVE
CHICAGO IL
60707-1601
US

IV. Provider business mailing address

9S616 HIGHLAND RD
WILLOWBROOK IL
60527-7017
US

V. Phone/Fax

Practice location:
  • Phone: 773-237-8855
  • Fax:
Mailing address:
  • Phone: 312-927-0537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.031220
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: