Provider Demographics
NPI:1245753573
Name:VARGHESE, IDA A (DDS)
Entity Type:Individual
Prefix:DR
First Name:IDA
Middle Name:A
Last Name:VARGHESE
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 1:611 S WELLS ST APT 2606
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4876
Mailing Address - Country:US
Mailing Address - Phone:832-206-4927
Mailing Address - Fax:
Practice Address - Street 1:2254 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2411
Practice Address - Country:US
Practice Address - Phone:708-656-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0310091223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice