Provider Demographics
NPI:1013693183
Name:TAKEDA, LIDIANE FUMIKO (DDS)
Entity Type:Individual
Prefix:
First Name:LIDIANE
Middle Name:FUMIKO
Last Name:TAKEDA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15630 ARIS CT
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-7712
Mailing Address - Country:US
Mailing Address - Phone:213-820-7456
Mailing Address - Fax:
Practice Address - Street 1:567 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2386
Practice Address - Country:US
Practice Address - Phone:708-283-9800
Practice Address - Fax:708-283-9801
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0345631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program