Provider Demographics
NPI:1164561114
Name:FIJAL, PHILLIP J
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:J
Last Name:FIJAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2335
Mailing Address - Country:US
Mailing Address - Phone:847-824-5252
Mailing Address - Fax:847-824-7434
Practice Address - Street 1:29 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-2335
Practice Address - Country:US
Practice Address - Phone:847-824-5252
Practice Address - Fax:847-824-7434
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1920121122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist