MEDICARE: PANHAVUT CHIM DMD

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
1	1223G0001X	General Practice Dentistry	019.031272	IL

General Provider Information

NPI Number	:	1700309812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PANHAVUT CHIM DMD

Provider Business Mailing Address
First Line	:	1439 CARRIAGE LN APT 3
Second Line	:
City	:	WESTMONT
State	:	IL
Zip	:	60559-3141
Country	:	US
Telephone Number	:	651-399-7041
Fax Number	:

Provider Business Practice Location Address
First Line	:	590 E NORTH AVE
Second Line	:
City	:	CAROL STREAM
State	:	IL
Zip	:	60188-2128
Country	:	US
Telephone Number	:	630-588-1800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2017
Last Update Date	:	03/17/2018

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Directions to “ PANHAVUT CHIM DMD” Practice Location

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