=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417695651
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANH DUC LE DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2022
-----------------------------------------------------
Last Update Date | 05/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1969 W OGDEN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-864-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11650 W HACKBARTH DR
-----------------------------------------------------
City | YOUNGTOWN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85363-1749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-489-3785
-----------------------------------------------------
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 | 019.033571
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------