Healthcare Provider Details

I. General information

NPI: 1255853446
Provider Name (Legal Business Name): NAM HOANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 07/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2529
US

IV. Provider business mailing address

1125 BAYTOWNE DR APT 28
CHAMPAIGN IL
61822-7979
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number018.002021
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: