Provider Demographics
NPI:1376533299
Name:CHIN, CHENG LI (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHENG
Middle Name:LI
Last Name:CHIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4103
Mailing Address - Country:US
Mailing Address - Phone:773-772-4114
Mailing Address - Fax:773-772-4114
Practice Address - Street 1:2021 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4103
Practice Address - Country:US
Practice Address - Phone:773-772-4114
Practice Address - Fax:773-772-4114
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-22
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190158111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3629607116009101Medicaid
IL19015811Medicaid