Provider Demographics
NPI:1942043815
Name:LI, JENNY (DMD)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:LI
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 1:7012 N BRADFORD PL
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8220
Mailing Address - Country:US
Mailing Address - Phone:309-621-3851
Mailing Address - Fax:
Practice Address - Street 1:5521 S KEDZIE AVE UNIT 105
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-2448
Practice Address - Country:US
Practice Address - Phone:773-434-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0351931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice