Healthcare Provider Details

I. General information

NPI: 1912764457
Provider Name (Legal Business Name): CYNTHIA UCHECHUKWU UDEH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S PAULINA ST
CHICAGO IL
60612-4353
US

IV. Provider business mailing address

811 S PAULINA ST STE 161
CHICAGO IL
60612-4353
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7546
  • Fax:
Mailing address:
  • Phone: 312-996-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD15026
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD15026
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD15026
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number021003473
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: