=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659170637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELGADO DMD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2025
-----------------------------------------------------
Last Update Date | 03/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3201 N WESTERN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-6325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-598-1019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70887
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44190-0887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-454-6000
-----------------------------------------------------
Fax | 315-410-5531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENROLLMENT TEAM LEAD
-----------------------------------------------------
Name | CHRISTINE BARBER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-454-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------