Healthcare Provider Details

I. General information

NPI: 1114068350
Provider Name (Legal Business Name): VI QUAN QUAN D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 W FULLERTON AVE
CHICAGO IL
60647-2243
US

IV. Provider business mailing address

2210 W. WABANSIA AVE, UNIT 404
CHICAGO IL
60647-5488
US

V. Phone/Fax

Practice location:
  • Phone: 773-235-0000
  • Fax:
Mailing address:
  • Phone: 773-405-4220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN012782
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: