Provider Demographics
NPI:1790389369
Name:LAFAZANOS, EFFIE (RDH PHDH)
Entity Type:Individual
Prefix:MRS
First Name:EFFIE
Middle Name:
Last Name:LAFAZANOS
Suffix:
Gender:F
Credentials:RDH PHDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 EAST TERRA COTTA AVE #218/220
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-455-5490
Mailing Address - Fax:815-455-5498
Practice Address - Street 1:820 EAST TERRA COTTA AVE #218/220
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-455-5490
Practice Address - Fax:815-455-5498
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.011312124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist