Provider Demographics
NPI:1184828352
Name:DEBOSSU, PHILIP DOMINIQUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:DOMINIQUE
Last Name:DEBOSSU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3069 W ARMITAGE AVE
Mailing Address - Street 2:STORE B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5936
Mailing Address - Country:US
Mailing Address - Phone:773-342-2628
Mailing Address - Fax:773-342-7280
Practice Address - Street 1:3069 W ARMITAGE AVE
Practice Address - Street 2:STORE B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5936
Practice Address - Country:US
Practice Address - Phone:773-342-2628
Practice Address - Fax:773-342-7280
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice