Provider Demographics
NPI:1417468315
Name:JAGIRDAR, ADIBA (DMD)
Entity Type:Individual
Prefix:
First Name:ADIBA
Middle Name:
Last Name:JAGIRDAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 N YORK ST APT 302
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1249
Mailing Address - Country:US
Mailing Address - Phone:630-923-9043
Mailing Address - Fax:
Practice Address - Street 1:75 W NORTH AVE STE 400
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-2314
Practice Address - Country:US
Practice Address - Phone:708-562-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0312901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice