Basic Information
| Provider Information | |||||||||
| NPI: | 1629007976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FROGAMENI | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 W SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606225646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126663494 | ||||||||
| FaxNumber: | 3126666228 | ||||||||
| Practice Location | |||||||||
| Address1: | 5215 N CALIFORNIA AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606257014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126663494 | ||||||||
| FaxNumber: | 3126666228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 11/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 30-018017 | OH | N | Dental Providers | Dentist | General Practice | 1223G0001X | 019-021744 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 019021744 | 05 | IL | MEDICAID | 2219281 | 05 | OH | MEDICAID | 600972 | 01 | OH | BUCKEYE GROUP ID | OTHER | 10246 | 01 | OH | GROUP PARAMOUNT ID | OTHER | 8822331 | 05 | OH | MEDICAID | 109100 | 01 | OH | DORAL DENTAL | OTHER | 88333OH | 01 | OH | DELTA DENTAL | OTHER |