=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285406413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNBURST DENTAL P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2023
-----------------------------------------------------
Last Update Date | 10/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1504 N NAPER BLVD STE 152
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60563-4819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-296-9297
-----------------------------------------------------
Fax | 630-296-9139
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1504 N NAPER BLVD STE 152
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60563-4819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-296-9297
-----------------------------------------------------
Fax | 630-296-9139
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HENG XU
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 630-296-9297
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------