Provider Demographics
NPI:1114097383
Name:FUENTESBURGOSSERVICECORPORATION
Entity Type:Organization
Organization Name:FUENTESBURGOSSERVICECORPORATION
Other - Org Name:LOS ANDES DENTAL AND MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NUBIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-264-8042
Mailing Address - Street 1:205 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60505-4240
Mailing Address - Country:US
Mailing Address - Phone:630-264-8042
Mailing Address - Fax:630-264-8139
Practice Address - Street 1:205 CLARK ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-4240
Practice Address - Country:US
Practice Address - Phone:630-264-8042
Practice Address - Fax:630-264-8139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty