=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316017338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREDERIC J MRUGALA D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6418 S CASS AVE
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-3209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-963-8680
-----------------------------------------------------
Fax | 630-963-5899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6305 W 92ND ST
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-599-6404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 19-15558
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------