Provider Demographics
NPI:1861168122
Name:BAE, TERESA (DMD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:
Last Name:BAE
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 1:1 E PHILLIP RD STE 102
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1858
Mailing Address - Country:US
Mailing Address - Phone:847-367-6055
Mailing Address - Fax:
Practice Address - Street 1:1 E PHILLIP RD STE 102
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1858
Practice Address - Country:US
Practice Address - Phone:847-367-6055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7752122300000X
IL019.0346701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist