Provider Demographics
NPI:1083911366
Name:CANDELARIA, ADELINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ADELINA
Middle Name:
Last Name:CANDELARIA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 N PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-4011
Mailing Address - Country:US
Mailing Address - Phone:773-282-2077
Mailing Address - Fax:773-282-4344
Practice Address - Street 1:3321 N. PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-5496
Practice Address - Country:US
Practice Address - Phone:773-282-2077
Practice Address - Fax:773-282-4344
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025189122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist