Provider Demographics
NPI:1821501495
Name:CHENEY, CLEO STEPHANIDES (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLEO
Middle Name:STEPHANIDES
Last Name:CHENEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CLEO
Other - Middle Name:DANUTA
Other - Last Name:STEPHANIDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1100 LAKE ST STE 140
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-6712
Mailing Address - Country:US
Mailing Address - Phone:708-383-1234
Mailing Address - Fax:
Practice Address - Street 1:1100 LAKE ST STE 140
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-6712
Practice Address - Country:US
Practice Address - Phone:708-383-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10743908-99221223G0001X
IL019.0331501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice