1801314505 NPI number — DR. CONSTANZA E FERNANDEZ GONZALEZ DDS, PHD

Table of content: DR. CONSTANZA E FERNANDEZ GONZALEZ DDS, PHD (NPI 1801314505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801314505 NPI number — DR. CONSTANZA E FERNANDEZ GONZALEZ DDS, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ GONZALEZ
Provider First Name:
CONSTANZA
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS, PHD
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:
1801314505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 31ST STREET
Provider Second Line Business Mailing Address:
SCIENCE HALL, SUITE 211 P
Provider Business Mailing Address City Name:
DOWNERS GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-515-7350
Provider Business Mailing Address Fax Number:
630-515-7290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3450 LACEY RD
Provider Second Line Business Practice Location Address:
DENTAL INSTITUTE
Provider Business Practice Location Address City Name:
DOWNERS GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-515-7350
Provider Business Practice Location Address Fax Number:
630-515-7290
Provider Enumeration Date:
09/01/2017

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: 122300000X , with the licence number:  136.000221 , 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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