Individual
JONATHAN PHEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
502 RIVERSIDE DR, EAST PEORIA, IL 61611-2068
(309) 606-5008
Mailing address
2121 45TH ST APT 2322, HIGHLAND, IN 46322-0006
(954) 997-4175
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
019034133
IL
Other
Enumeration date
04/05/2023
Last updated
04/10/2023
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