Provider Demographics
NPI:1790358315
Name:IM, CHRISTINA CHAE HYUN (DMD)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:CHAE HYUN
Last Name:IM
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 1:728 N MORGAN ST APT 603
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-6583
Mailing Address - Country:US
Mailing Address - Phone:773-655-9191
Mailing Address - Fax:
Practice Address - Street 1:3014 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-5805
Practice Address - Country:US
Practice Address - Phone:312-291-9283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033310122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist