Provider Demographics
NPI:1154595106
Name:CHENG LI CHIN D.D.S.
Entity type:Organization
Organization Name:CHENG LI CHIN D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHENG
Authorized Official - Middle Name:LI
Authorized Official - Last Name:CHIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-772-4114
Mailing Address - Street 1:2021 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4103
Mailing Address - Country:US
Mailing Address - Phone:773-772-4114
Mailing Address - Fax:773-772-4114
Practice Address - Street 1:2021 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4103
Practice Address - Country:US
Practice Address - Phone:773-772-4114
Practice Address - Fax:773-772-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190158111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6009101Medicaid