Provider Demographics
NPI:1942589643
Name:MUKARAKATE, FADZANAI
Entity Type:Individual
Prefix:
First Name:FADZANAI
Middle Name:
Last Name:MUKARAKATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3122 W KUNKLE BLVD
Mailing Address - Street 2:UNIT #4
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032
Mailing Address - Country:US
Mailing Address - Phone:615-738-8743
Mailing Address - Fax:815-801-7652
Practice Address - Street 1:2661 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032
Practice Address - Country:US
Practice Address - Phone:815-233-1215
Practice Address - Fax:815-801-7652
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190288291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice