Healthcare Provider Details

I. General information

NPI: 1851083331
Provider Name (Legal Business Name): GABRIELLA TATIANA BRIGANDO DMD, MBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 N GALENA AVE
DIXON IL
61021-1009
US

IV. Provider business mailing address

9000 S 85TH CT
HICKORY HILLS IL
60457-1331
US

V. Phone/Fax

Practice location:
  • Phone: 815-284-1995
  • Fax:
Mailing address:
  • Phone: 708-217-4465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.034206
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: