Provider Demographics
NPI:1700309812
Name:CHIM, PANHAVUT (DMD)
Entity Type:Individual
Prefix:
First Name:PANHAVUT
Middle Name:
Last Name:CHIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 CARRIAGE LN APT 3
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-3141
Mailing Address - Country:US
Mailing Address - Phone:651-399-7041
Mailing Address - Fax:
Practice Address - Street 1:590 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2128
Practice Address - Country:US
Practice Address - Phone:630-588-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0312721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice