Provider Demographics
NPI:1346587797
Name:CHAVEZ, EDWARD ROGER
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ROGER
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E WILLOW AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5463
Mailing Address - Country:US
Mailing Address - Phone:630-510-0731
Mailing Address - Fax:630-510-9779
Practice Address - Street 1:200 E WILLOW AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5463
Practice Address - Country:US
Practice Address - Phone:630-510-0731
Practice Address - Fax:630-510-9779
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019017516122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist