Provider Demographics
NPI:1528122512
Name:FUNG, CHI MING HENRY (DDS)
Entity type:Individual
Prefix:DR
First Name:CHI MING HENRY
Middle Name:
Last Name:FUNG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:HENRY C.
Other - Middle Name:
Other - Last Name:FUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:821 S OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1217
Mailing Address - Country:US
Mailing Address - Phone:708-383-8228
Mailing Address - Fax:708-383-8288
Practice Address - Street 1:821 S OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1217
Practice Address - Country:US
Practice Address - Phone:708-383-8228
Practice Address - Fax:708-383-8288
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210013601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL840500280Medicare PIN
IL984960Medicare ID - Type Unspecified
ILU-33761Medicare UPIN