Provider Demographics
NPI:1902192495
Name:ESCOBAR, BLEIDY MARCELA (DDS)
Entity Type:Individual
Prefix:MISS
First Name:BLEIDY
Middle Name:MARCELA
Last Name:ESCOBAR
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 1:401 W FULLERTON PKWY APT 606E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2802
Mailing Address - Country:US
Mailing Address - Phone:773-391-1478
Mailing Address - Fax:
Practice Address - Street 1:4148 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-1825
Practice Address - Country:US
Practice Address - Phone:773-247-3345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist