Healthcare Provider Details

I. General information

NPI: 1174378269
Provider Name (Legal Business Name): CLAUDIA YEAH DIBOUH NYOH-TABI STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 W GLEN AVE
PEORIA IL
61614-4705
US

IV. Provider business mailing address

1 KNEELAND ST
BOSTON MA
02111-1527
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-4721
  • Fax:
Mailing address:
  • Phone: 617-636-6828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number319.025427
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037348
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number42712
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: