Provider Demographics
NPI:1285024281
Name:SARA BANUELOS D.D.S SC
Entity type:Organization
Organization Name:SARA BANUELOS D.D.S SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:IBARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-241-0666
Mailing Address - Street 1:3800 HIGHLAND AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1557
Mailing Address - Country:US
Mailing Address - Phone:630-241-0666
Mailing Address - Fax:630-241-7275
Practice Address - Street 1:3800 HIGHLAND AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1557
Practice Address - Country:US
Practice Address - Phone:630-241-0666
Practice Address - Fax:630-241-7275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021895122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherSOLO PRACTITIONER