Provider Demographics
NPI:1053603365
Name:OPON, CANDACE MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:MARIE
Last Name:OPON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 N. ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012
Mailing Address - Country:US
Mailing Address - Phone:815-477-2177
Mailing Address - Fax:815-477-8671
Practice Address - Street 1:690 N IL ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3790
Practice Address - Country:US
Practice Address - Phone:815-477-2177
Practice Address - Fax:815-477-2671
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0238661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice