PHENNATDA POLPORNVITOON DMD - Dentist License in Illinois | # 31*****86

PHENNATDA POLPORNVITOON DMD

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****86

License Status

NOT RENEWED

Business

N

Title

DMD

First Name

PHENNATDA

Last Name

POLPORNVITOON

Business Name

PHENNATDA POLPORNVITOON DMD

Original Issue Date

11/05/2020

Effective Date

11/05/2020

Expiration Date

01/31/2022

City

CHICAGO

State

IL

Zip

60612

County

COOK

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

N

LastModifiedDate

05/09/2022