Provider Demographics
NPI:1154706364
Name:GARCIA, ANDRE ELIAS (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:ELIAS
Last Name:GARCIA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 W PRATT AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-3828
Mailing Address - Country:US
Mailing Address - Phone:224-522-8484
Mailing Address - Fax:
Practice Address - Street 1:3355 W PRATT AVE
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-3828
Practice Address - Country:US
Practice Address - Phone:224-522-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL319019588OtherCONTROLLED SUBSTANCE LICENSE
IL019030360OtherLICENSE NUMBER