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General NPI Number Information
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NPI Number | 1164123642
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Entity Type | Individual
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Provider Name | QIAO FANG DDS
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Gender | Male
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Dates
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Enumeration Date | 03/13/2023
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Last Update Date | 03/13/2023
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Provider Practice Location Address
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Address Line | 801 S PAULINA ST
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City | CHICAGO
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State | IL
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Zip | 60612-7210
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Country | US
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Telephone | 312-355-0435
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Fax |
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Provider Business Mailing Address
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Address Line | 1922 W OGDEN AVE UNIT 1202
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City | CHICAGO
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State | IL
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Zip | 60612-5585
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Country | US
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Telephone | 909-312-8582
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019-033057
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License Number State | IL
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