=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114097383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUENTESBURGOSSERVICECORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 CLARK ST
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60505-4240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-264-8042
-----------------------------------------------------
Fax | 630-264-8139
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 CLARK ST
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60505-4240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-264-8042
-----------------------------------------------------
Fax | 630-264-8139
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. NUBIA E. FUENTES
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 630-264-8042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------