Provider Demographics
NPI:1164042198
Name:DEJONGE, LYDIA JAEL (DDS)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:JAEL
Last Name:DEJONGE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6305 W 95TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2795
Mailing Address - Country:US
Mailing Address - Phone:708-424-1300
Mailing Address - Fax:
Practice Address - Street 1:6305 W 95TH ST STE 200
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2795
Practice Address - Country:US
Practice Address - Phone:708-424-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL021.0032851223P0221X
IL019.0328381223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program