Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019.028216 | IL |
NPI | 1003130816 |
---|---|
Provider Name | Thaize Lara Melo |
First Address | Chicago, IL 60607-2243 |
Second Address | Chicago, IL 60607-2243 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2010 |
Last Update Date | 21/11/2013 |