Organization
MEFAGUI DENTAL OFFICE P.C.
Active
Other names
Mefagui Dental Office
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ELSA GAMBOA DDS (PRESIDENT)
(773) 622-4006
Entity
Organization
Contact information
Practice address
6913 W. GRAND AVE, CHICAGO, IL 60707
(773) 622-4006
(773) 622-4114
Mailing address
6913 W. GRAND AVE, CHICAGO, IL 60707
(773) 622-4006
(773) 622-4114
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
019022954
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1001939
—
IL
Enumeration date
10/09/2008
Last updated
10/09/2008
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