Provider Demographics
NPI:1649708033
Name:THORNTON, IVANA FRAGA (DDS)
Entity type:Individual
Prefix:DR
First Name:IVANA
Middle Name:FRAGA
Last Name:THORNTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:IVANA
Other - Middle Name:COSTA
Other - Last Name:FRAGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2727 E BEECHER ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-3506
Mailing Address - Country:US
Mailing Address - Phone:517-265-3900
Mailing Address - Fax:
Practice Address - Street 1:2727 E BEECHER ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-3506
Practice Address - Country:US
Practice Address - Phone:517-263-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022179122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist