Provider Demographics
NPI:1437720695
Name:DEFRIES, SARAH CATHERINE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:CATHERINE
Last Name:DEFRIES
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 1:381 SOUTHWIND CT
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6687
Mailing Address - Country:US
Mailing Address - Phone:224-426-7066
Mailing Address - Fax:
Practice Address - Street 1:4310 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4009
Practice Address - Country:US
Practice Address - Phone:224-426-7066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033302122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019.033302Medicaid