Provider Demographics
NPI:1659840908
Name:CHI, HOGEUN
Entity Type:Individual
Prefix:DR
First Name:HOGEUN
Middle Name:
Last Name:CHI
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 1:3215 FRIENDSHIP DR
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-6152
Mailing Address - Country:US
Mailing Address - Phone:929-600-4973
Mailing Address - Fax:
Practice Address - Street 1:4601 16TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7000
Practice Address - Country:US
Practice Address - Phone:309-797-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0319341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019.031934Medicaid