Provider Demographics
NPI:1184291163
Name:AGRAWAL, DIKSHA
Entity type:Individual
Prefix:
First Name:DIKSHA
Middle Name:
Last Name:AGRAWAL
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 1:633 S LAFLIN ST APT 8
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3113
Mailing Address - Country:US
Mailing Address - Phone:215-609-9648
Mailing Address - Fax:
Practice Address - Street 1:1767 W OGDEN AVE STE 123
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-3956
Practice Address - Country:US
Practice Address - Phone:630-983-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist