Healthcare Provider Details

I. General information

NPI: 1790948107
Provider Name (Legal Business Name): CHRISTINE DAGENAIS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27W701 SWAN LAKE DR
WHEATON IL
60187-6008
US

IV. Provider business mailing address

27W701 SWAN LAKE DR
WHEATON IL
60187-6008
US

V. Phone/Fax

Practice location:
  • Phone: 630-260-9345
  • Fax:
Mailing address:
  • Phone: 630-260-9345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number160000127
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: