Provider Demographics
NPI:1134712524
Name:VIRJI, INSIA FATEMA (DMD)
Entity type:Individual
Prefix:DR
First Name:INSIA
Middle Name:FATEMA
Last Name:VIRJI
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 1:1530 S STATE ST APT 821
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2983
Mailing Address - Country:US
Mailing Address - Phone:630-414-9839
Mailing Address - Fax:
Practice Address - Street 1:2605 GRAND AVE STE A
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2410
Practice Address - Country:US
Practice Address - Phone:847-244-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0329841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice