Provider Demographics
NPI:1003117631
Name:FREGOZO, ILLIMANI LESBIA (RDH)
Entity Type:Individual
Prefix:
First Name:ILLIMANI
Middle Name:LESBIA
Last Name:FREGOZO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 HELEN RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2712
Mailing Address - Country:US
Mailing Address - Phone:650-773-9043
Mailing Address - Fax:
Practice Address - Street 1:2100 MONUMENT BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-3489
Practice Address - Country:US
Practice Address - Phone:925-363-1256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25607124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist