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General NPI Number Information
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NPI Number | 1699252833
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Entity Type | Individual
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Provider Name | CAMILA PERALTA-SUGANO DMD
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Gender | Female
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Dates
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Enumeration Date | 07/20/2018
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Last Update Date | 05/17/2021
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Provider Practice Location Address
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Address Line | 6735 STANLEY AVE
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City | BERWYN
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State | IL
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Zip | 60402-3129
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Country | US
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Telephone | 708-484-0212
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Fax |
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Provider Business Mailing Address
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Address Line | 3752 N TROY ST APT 1
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City | CHICAGO
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State | IL
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Zip | 60618-4506
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Country | US
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Telephone | 773-710-7270
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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 | 019031784
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License Number State | IL
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