Healthcare Provider Details

I. General information

NPI: 1366253916
Provider Name (Legal Business Name): JESSIE ZHU DMD MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 S WAUKEGAN RD STE 101
LAKE FOREST IL
60045-2672
US

IV. Provider business mailing address

1850 GREEN BAY RD # W303
HIGHLAND PARK IL
60035-3136
US

V. Phone/Fax

Practice location:
  • Phone: 847-615-5437
  • Fax:
Mailing address:
  • Phone: 859-433-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number019.035677
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: