Healthcare Provider Details

I. General information

NPI: 1851587158
Provider Name (Legal Business Name): FABIANA MARIA ESPINDOLA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FABIANA ESPINDOLA DMD

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6153 S WESTERN AVE
CHICAGO IL
60636-2047
US

IV. Provider business mailing address

5202 S DREXEL AVE
CHICAGO IL
60615-3721
US

V. Phone/Fax

Practice location:
  • Phone: 773-677-7903
  • Fax:
Mailing address:
  • Phone: 773-677-7903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 18146
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019027849
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: