Healthcare Provider Details

I. General information

NPI: 1013693183
Provider Name (Legal Business Name): LIDIANE FUMIKO TAKEDA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

567 W 14TH ST
CHICAGO HEIGHTS IL
60411-2386
US

IV. Provider business mailing address

15630 ARIS CT
ORLAND PARK IL
60462-7712
US

V. Phone/Fax

Practice location:
  • Phone: 708-283-9800
  • Fax: 708-283-9801
Mailing address:
  • Phone: 213-820-7456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.034563
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: