Healthcare Provider Details

I. General information

NPI: 1396232138
Provider Name (Legal Business Name): MR. WINSTON FENG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4108 N SHERIDAN RD
CHICAGO IL
60613-2007
US

IV. Provider business mailing address

515 ILLINOIS RD
WILMETTE IL
60091-2340
US

V. Phone/Fax

Practice location:
  • Phone: 773-549-6116
  • Fax:
Mailing address:
  • Phone: 847-529-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19031747
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: