Healthcare Provider Details

I. General information

NPI: 1831411990
Provider Name (Legal Business Name): VI Q QUAN DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2010
Last Update Date: 02/17/2010
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

7723 W CLARENCE AVE
CHICAGO IL
60631-1833
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 TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-026196
License Number StateIL

VIII. Authorized Official

Name: DR. VI QUAN QUAN
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 773-405-4220