Provider Demographics
NPI:1437191871
Name:CRISOSTOMO, PATRICIA BETTINA CARIAGA (DMD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:BETTINA CARIAGA
Last Name:CRISOSTOMO
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 1:3600 N LAKE SHORE DR APT 2712
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4666
Mailing Address - Country:US
Mailing Address - Phone:773-793-0836
Mailing Address - Fax:
Practice Address - Street 1:3403 W LAWRENCE AVE STE 202
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5162
Practice Address - Country:US
Practice Address - Phone:773-539-1003
Practice Address - Fax:773-539-1036
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2023-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025133122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist