Provider Demographics
NPI:1790851053
Name:DZIEDZIECH, AGATHA NATASHA (DDS)
Entity Type:Individual
Prefix:DR
First Name:AGATHA
Middle Name:NATASHA
Last Name:DZIEDZIECH
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 1:2058 N BURLING ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4412
Mailing Address - Country:US
Mailing Address - Phone:312-925-7995
Mailing Address - Fax:
Practice Address - Street 1:100 E WALTON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1448
Practice Address - Country:US
Practice Address - Phone:312-925-7995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist