Healthcare Provider Details

I. General information

NPI: 1689170318
Provider Name (Legal Business Name): MI DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 S ELMHURST RD
MT PROSPECT IL
60056-4240
US

IV. Provider business mailing address

39 ORRINGTON CT
SCHAUMBURG IL
60173-2116
US

V. Phone/Fax

Practice location:
  • Phone: 646-761-5224
  • Fax:
Mailing address:
  • Phone: 646-761-5224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number019028417
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019028417
License Number StateIL

VIII. Authorized Official

Name: DR. HYUN MIN KIM
Title or Position: DENTIST
Credential: DDS
Phone: 646-761-5224