Provider Demographics
NPI:1508437765
Name:SOMERS, MEDALITH YASMINE
Entity Type:Individual
Prefix:
First Name:MEDALITH
Middle Name:YASMINE
Last Name:SOMERS
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 1:1363 FAIRFIELD CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-2967
Mailing Address - Country:US
Mailing Address - Phone:630-885-1131
Mailing Address - Fax:
Practice Address - Street 1:1363 FAIRFIELD CT
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60565-2967
Practice Address - Country:US
Practice Address - Phone:630-885-1131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0332291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice