Healthcare Provider Details

I. General information

NPI: 1073206942
Provider Name (Legal Business Name): VIVIAN LEE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 W LAKE ST
BLOOMINGDALE IL
60108-1027
US

IV. Provider business mailing address

200 N ARLINGTON HEIGHTS RD APT 907
ARLINGTON HEIGHTS IL
60004-6052
US

V. Phone/Fax

Practice location:
  • Phone: 630-307-3133
  • Fax:
Mailing address:
  • Phone: 224-475-3236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.035322
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: