Provider Demographics
NPI:1386304806
Name:MORALES, CAROLA
Entity type:Individual
Prefix:
First Name:CAROLA
Middle Name:
Last Name:MORALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 S MENARD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-5426
Mailing Address - Country:US
Mailing Address - Phone:773-653-5714
Mailing Address - Fax:
Practice Address - Street 1:1220 S WOOD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1202
Practice Address - Country:US
Practice Address - Phone:312-996-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.015581124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist