Provider Demographics
NPI:1114068350
Name:QUAN, VI QUAN (DMD)
Entity Type:Individual
Prefix:
First Name:VI
Middle Name:QUAN
Last Name:QUAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 W. WABANSIA AVE,
Mailing Address - Street 2:UNIT 404
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5488
Mailing Address - Country:US
Mailing Address - Phone:773-405-4220
Mailing Address - Fax:
Practice Address - Street 1:3939 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2243
Practice Address - Country:US
Practice Address - Phone:773-235-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012782122300000X
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist