=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366431371
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHI-ING LI D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2005
-----------------------------------------------------
Last Update Date | 10/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 746 W 79TH ST CHICAGO
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60620-2424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-488-5282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1920 S LOUIE PKWY CHICAGO
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60616-5011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-225-6808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019017933
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------