1629007976 NPI number — DEBORAH FROGAMENI DDS

Table of content: DEBORAH FROGAMENI DDS (NPI 1629007976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629007976 NPI number — DEBORAH FROGAMENI DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FROGAMENI
Provider First Name:
DEBORAH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629007976
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 W SUPERIOR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60622-5646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-666-3494
Provider Business Mailing Address Fax Number:
312-666-6228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5215 N CALIFORNIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60625-7014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-666-3494
Provider Business Practice Location Address Fax Number:
312-666-6228
Provider Enumeration Date:
06/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  30-018017 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 019-021744 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 019021744 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2219281 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 600972 . This is a "BUCKEYE GROUP ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 10246 . This is a "GROUP PARAMOUNT ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 8822331 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 109100 . This is a "DORAL DENTAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 88333OH . This is a "DELTA DENTAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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