Provider Demographics
NPI:1619037322
Name:MURILLO, BLANCA ESTELA (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLANCA
Middle Name:ESTELA
Last Name:MURILLO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 N WESTERN AVE
Mailing Address - Street 2:DENTAL OFFICE
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1746
Mailing Address - Country:US
Mailing Address - Phone:773-772-7744
Mailing Address - Fax:773-772-7045
Practice Address - Street 1:1504 N WESTERN AVE
Practice Address - Street 2:DENTAL OFFICE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1746
Practice Address - Country:US
Practice Address - Phone:773-772-7744
Practice Address - Fax:773-772-7045
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190265781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9177501Medicaid