MEDICARE: CHRISTINA CHAE HYUN IM 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	122300000X	Dentist	019.033310	IL

General Provider Information

NPI Number	:	1790358315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA CHAE HYUN IM DMD

Provider Business Mailing Address
First Line	:	728 N MORGAN ST APT 603
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-6583
Country	:	US
Telephone Number	:	773-655-9191
Fax Number	:

Provider Business Practice Location Address
First Line	:	3014 S HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-5805
Country	:	US
Telephone Number	:	312-291-9283
Fax Number	:

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

Provider Enumeration Date	:	07/21/2021
Last Update Date	:	07/21/2021

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