Provider Demographics
NPI:1417946641
Name:LIM, PETER S
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:LIM
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 1:2316 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2228
Mailing Address - Country:US
Mailing Address - Phone:312-491-0601
Mailing Address - Fax:312-491-0602
Practice Address - Street 1:2316 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2228
Practice Address - Country:US
Practice Address - Phone:312-491-0601
Practice Address - Fax:312-491-0602
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0263441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice