=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740299841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELOISE B. FRYE RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5129 W DEVON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-4217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-631-5788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3813 LANKFORD TRL
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-9571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-741-2897
-----------------------------------------------------
Fax | 309-213-1411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------