Provider Demographics
NPI:1124290671
Name:NUCUM, MAGDALENO S (DDS)
Entity type:Individual
Prefix:DR
First Name:MAGDALENO
Middle Name:S
Last Name:NUCUM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 N MULLIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1812
Mailing Address - Country:US
Mailing Address - Phone:773-631-1794
Mailing Address - Fax:
Practice Address - Street 1:287 N WEBER RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-1567
Practice Address - Country:US
Practice Address - Phone:630-226-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice