Provider Demographics
NPI:1346226651
Name:BALQUIEDRA, LOURDES ELENTO (DDS)
Entity Type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:ELENTO
Last Name:BALQUIEDRA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:LOURDES
Other - Middle Name:BALQUIEDRA
Other - Last Name:SEVENDAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:3339 WEST 55TH STREET FRONT
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632
Mailing Address - Country:US
Mailing Address - Phone:773-436-1236
Mailing Address - Fax:
Practice Address - Street 1:3339 WEST 55TH STREET FRONT
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632
Practice Address - Country:US
Practice Address - Phone:773-436-1236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist