Provider Demographics
NPI:1669355434
Name:BIG WAVE DENTAL PC
Entity type:Organization
Organization Name:BIG WAVE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIT
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-465-8627
Mailing Address - Street 1:3739 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3827
Mailing Address - Country:US
Mailing Address - Phone:773-762-0626
Mailing Address - Fax:
Practice Address - Street 1:3739 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3827
Practice Address - Country:US
Practice Address - Phone:773-762-0626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty