Provider Demographics
NPI:1306407812
Name:CAICEDO MORENO, CHRISTIAN XAVIER (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:XAVIER
Last Name:CAICEDO MORENO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3214 N NORDICA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4505
Mailing Address - Country:US
Mailing Address - Phone:813-598-8638
Mailing Address - Fax:
Practice Address - Street 1:5521 S KEDZIE AVE UNIT 105
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-2448
Practice Address - Country:US
Practice Address - Phone:773-434-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032183122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019.032183OtherDENTAL LICENSE