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General NPI Number Information
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NPI Number | 1184780876
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Entity Type | Organization
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Legal Business Name | SUZY AZALEA DMD LDT
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Dates
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Enumeration Date | 12/28/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 761 E BOUGHTON RD
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City | BOLINGBROOK
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State | IL
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Zip | 60440
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Country | US
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Telephone | 630-739-9430
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Fax |
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Provider Business Mailing Address
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Address Line | 761 E BOUGHTON RD
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City | BOLINGBROOK
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State | IL
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Zip | 60440
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Country | US
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Telephone | 630-739-9430
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. SUZY AZALEA
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Credential | DMD
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Telephone | 630-739-9430
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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 |
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License Number State | IL
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