Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 020.014003 | IL |
NPI | 1013262401 |
---|---|
Provider Name | Alfredo Carrasquillo |
First Address | Chicago, IL 60641-5441 |
Second Address | Chicago, IL 60641-5441 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2012 |
Last Update Date | 21/07/2012 |