Provider Demographics
NPI:1255434700
Name:ADAM, ANDREA (DDS)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ADAM
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 1:40W320 LAFOX RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-6545
Mailing Address - Country:US
Mailing Address - Phone:630-762-0000
Mailing Address - Fax:630-762-9966
Practice Address - Street 1:40W320 LAFOX RD
Practice Address - Street 2:SUITE D
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-6545
Practice Address - Country:US
Practice Address - Phone:630-762-0000
Practice Address - Fax:630-762-9966
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist