Provider Demographics
NPI:1699252833
Name:PERALTA-SUGANO, CAMILA (DMD)
Entity type:Individual
Prefix:
First Name:CAMILA
Middle Name:
Last Name:PERALTA-SUGANO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3752 N TROY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4506
Mailing Address - Country:US
Mailing Address - Phone:773-710-7270
Mailing Address - Fax:
Practice Address - Street 1:6735 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3129
Practice Address - Country:US
Practice Address - Phone:708-484-0212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031784122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist