Provider Demographics
NPI:1689993818
Name:BEAUDETTE-NGUYEN, LISA MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:BEAUDETTE-NGUYEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:BAUDETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2424 W. PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659
Mailing Address - Country:US
Mailing Address - Phone:773-761-0300
Mailing Address - Fax:773-761-0009
Practice Address - Street 1:2424 W. PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659
Practice Address - Country:US
Practice Address - Phone:773-761-0300
Practice Address - Fax:773-761-0009
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190282771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019028277Medicaid