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NPI Code Detail

MEDICARE: LIDIANE FUMIKO TAKEDA DDS

MEDICARE: LIDIANE FUMIKO TAKEDA DDS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program
21223G0001XGeneral Practice Dentistry019.034563IL

General Provider Information

NPI Number : 1013693183
Entity Type Code : Individual
Provider Name (Legal Business Name) : LIDIANE FUMIKO TAKEDA DDS
Provider Business Mailing Address
First Line : 15630 ARIS CT
Second Line :
City : ORLAND PARK
State : IL
Zip : 60462-7712
Country : US
Telephone Number : 213-820-7456
Fax Number :
Provider Business Practice Location Address
First Line : 567 W 14TH ST
Second Line :
City : CHICAGO HEIGHTS
State : IL
Zip : 60411-2386
Country : US
Telephone Number : 708-283-9800
Fax Number : 708-283-9801
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/23/2023
Last Update Date : 08/03/2023

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Directions to “ LIDIANE FUMIKO TAKEDA DDS” Practice Location

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