Healthcare Provider Details

I. General information

NPI: 1366936627
Provider Name (Legal Business Name): LAUREL VANA FRAUSTO DMD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 W BUTTERFIELD RD STE 180
ELMHURST IL
60126-5099
US

IV. Provider business mailing address

753 N LOMBARD ST
ELMHURST IL
60126-1727
US

V. Phone/Fax

Practice location:
  • Phone: 630-832-3120
  • Fax:
Mailing address:
  • Phone: 630-217-1208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.031612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: