Provider Demographics
NPI:1376792333
Name:LUTIN, ELIANORA A
Entity Type:Individual
Prefix:
First Name:ELIANORA
Middle Name:A
Last Name:LUTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4640
Mailing Address - Country:US
Mailing Address - Phone:773-782-8900
Mailing Address - Fax:773-782-0577
Practice Address - Street 1:3855 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4640
Practice Address - Country:US
Practice Address - Phone:773-782-8900
Practice Address - Fax:773-782-0577
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILL35020180940122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist