Healthcare Provider Details

I. General information

NPI: 1932266616
Provider Name (Legal Business Name): BRYAN R. CICHON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S RANDALL RD SUITE #1
ST CHARLES IL
60174-5916
US

IV. Provider business mailing address

1107 INDEPENDENCE AVE
ELBURN IL
60119-7833
US

V. Phone/Fax

Practice location:
  • Phone: 630-587-2600
  • Fax: 630-587-2605
Mailing address:
  • Phone: 630-587-2600
  • Fax: 630-587-2605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-023433
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: