Healthcare Provider Details

I. General information

NPI: 1407379936
Provider Name (Legal Business Name): PETER SHIH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 N 9TH ST
SPRINGFIELD IL
62702-6309
US

IV. Provider business mailing address

2050 E ALGONQUIN RD STE 610
SCHAUMBURG IL
60173-4166
US

V. Phone/Fax

Practice location:
  • Phone: 888-988-4066
  • Fax: 888-988-4066
Mailing address:
  • Phone: 888-988-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number019031260
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: