Provider Demographics
NPI:1356964480
Name:ABRAHAM, PHEBA MARIN (DMD)
Entity type:Individual
Prefix:
First Name:PHEBA
Middle Name:MARIN
Last Name:ABRAHAM
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 1:801 S PAULINA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7210
Mailing Address - Country:US
Mailing Address - Phone:678-372-4690
Mailing Address - Fax:
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:678-372-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-23
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0325741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics