Provider Demographics
NPI:1689377319
Name:GUZMAN, LARA ADAMILKA (DMD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:ADAMILKA
Last Name:GUZMAN
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 1:215 EAST ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-1308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 E SUPERIOR ST STE 9-900
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4494
Practice Address - Country:US
Practice Address - Phone:312-227-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist