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General NPI Number Information
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NPI Number | 1053936153
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Entity Type | Individual
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Provider Name | CRISTIANE GURGEL DO AMARAL JEREISSATI
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Gender | Female
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Dates
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Enumeration Date | 06/15/2020
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Last Update Date | 06/16/2020
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Provider Practice Location Address
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Address Line | 156 E LAKE ST
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1184
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Country | US
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Telephone | 224-231-4638
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Fax |
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Provider Business Mailing Address
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Address Line | 2620 MAPLESIDE LN
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City | AURORA
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State | IL
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Zip | 60502-9104
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Country | US
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Telephone | 630-730-1610
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.032668
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License Number State | IL
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