Healthcare Provider Details

I. General information

NPI: 1134370059
Provider Name (Legal Business Name): MEFAGUI DENTAL OFFICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6913 W. GRAND AVE
CHICAGO IL
60707
US

IV. Provider business mailing address

6913 W. GRAND AVE
CHICAGO IL
60707
US

V. Phone/Fax

Practice location:
  • Phone: 773-622-4006
  • Fax: 773-622-4114
Mailing address:
  • Phone: 773-622-4006
  • Fax: 773-622-4114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019022954
License Number StateIL

VIII. Authorized Official

Name: DR. ELSA GAMBOA
Title or Position: PRESIDENT
Credential: DDS
Phone: 773-622-4006