Provider Demographics
NPI:1639721483
Name:BRICENO, JUANA ADILENE (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:
First Name:JUANA
Middle Name:ADILENE
Last Name:BRICENO
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 W CALENDAR AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2365
Mailing Address - Country:US
Mailing Address - Phone:708-579-2420
Mailing Address - Fax:
Practice Address - Street 1:23 W CALENDAR AVE FL 2
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2365
Practice Address - Country:US
Practice Address - Phone:708-579-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020016029124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist