Provider Demographics
NPI:1417005109
Name:BRODALA, NADINE (DDS, MS, DMD)
Entity Type:Individual
Prefix:DR
First Name:NADINE
Middle Name:
Last Name:BRODALA
Suffix:
Gender:F
Credentials:DDS, MS, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E WASHINGTON ST
Mailing Address - Street 2:1125
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1708
Mailing Address - Country:US
Mailing Address - Phone:312-641-2572
Mailing Address - Fax:
Practice Address - Street 1:25 E WASHINGTON ST
Practice Address - Street 2:1125
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1708
Practice Address - Country:US
Practice Address - Phone:312-641-2572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00481223P0300X
WADE95031223P0300X
IL019028809122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0300XDental ProvidersDentistPeriodontics