MEDICARE: KINTSUGI GROUP PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1477409829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINTSUGI GROUP PLLC

Provider Business Mailing Address
First Line	:	1879 N MILWAUKEE AVE STE 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5689
Country	:	US
Telephone Number	:	312-429-6506
Fax Number	:

Provider Business Practice Location Address
First Line	:	1879 N MILWAUKEE AVE STE 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5689
Country	:	US
Telephone Number	:	312-429-6506
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LUIS PERALTA
Credential	:	DMD
Telephone Number	:	917-742-4608

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	03/09/2026

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