Healthcare Provider Details

I. General information

NPI: 1417823501
Provider Name (Legal Business Name): WATCHARIYAPORN THASAI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 N KEDZIE AVE
CHICAGO IL
60625-5009
US

IV. Provider business mailing address

404 E CLARK ST APT 109
CHAMPAIGN IL
61820-5208
US

V. Phone/Fax

Practice location:
  • Phone: 773-895-9202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019035849
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: