Provider Demographics
NPI:1538565353
Name:LARA, MARIA S (RDH)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:S
Last Name:LARA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 W. PETERSON
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659
Mailing Address - Country:US
Mailing Address - Phone:773-761-0300
Mailing Address - Fax:773-761-0009
Practice Address - Street 1:2424 W. PETERSON
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659
Practice Address - Country:US
Practice Address - Phone:773-761-0300
Practice Address - Fax:773-761-0009
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.014789124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist