1730526054 NPI number — DR. GINA LYN TAMBORNINI D.D.S.

Table of content: DR. GINA LYN TAMBORNINI D.D.S. (NPI 1730526054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730526054 NPI number — DR. GINA LYN TAMBORNINI D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAMBORNINI
Provider First Name:
GINA
Provider Middle Name:
LYN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
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:
1730526054
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1640 N WELLS ST
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60614-6087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-642-4218
Provider Business Mailing Address Fax Number:
312-642-6419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 N WELLS ST
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60614-6087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-642-4218
Provider Business Practice Location Address Fax Number:
312-642-6419
Provider Enumeration Date:
05/28/2013

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:  019023206 , 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)





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