Healthcare Provider Details

I. General information

NPI: 1841829090
Provider Name (Legal Business Name): STEVEN LICHT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 07/11/2020
Certification Date: 07/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

801 S PAULINA ST RM 110
CHICAGO IL
60612-7210
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7555
  • Fax:
Mailing address:
  • Phone: 312-996-1052
  • Fax: 312-996-5987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019.032679
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: