Provider Demographics
NPI:1427889856
Name:SUVAGIA, MIRA (DMD, MS)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:SUVAGIA
Suffix:
Gender:
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9N946 HEATHERINGTON PL
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124-8351
Mailing Address - Country:US
Mailing Address - Phone:630-338-7740
Mailing Address - Fax:
Practice Address - Street 1:1137 N PROSPECT AVE # C101
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-1437
Practice Address - Country:US
Practice Address - Phone:630-338-7740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033765122300000X
IL021.0033891223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist