Healthcare Provider Details

I. General information

NPI: 1164561114
Provider Name (Legal Business Name): DR. PHILLIP J FIJAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 N BROADWAY ST
DES PLAINES IL
60016-2335
US

IV. Provider business mailing address

29 N BROADWAY ST
DES PLAINES IL
60016-2335
US

V. Phone/Fax

Practice location:
  • Phone: 847-824-5252
  • Fax: 847-824-7434
Mailing address:
  • Phone: 847-824-5252
  • Fax: 847-824-7434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1920121
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: