Healthcare Provider Details

I. General information

NPI: 1770700536
Provider Name (Legal Business Name): CRAIG KOSTRUBALA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11107 S LAWLER AVE
ALSIP IL
60803-6038
US

IV. Provider business mailing address

11107 S LAWLER AVE
ALSIP IL
60803-6038
US

V. Phone/Fax

Practice location:
  • Phone: 708-346-9600
  • Fax:
Mailing address:
  • Phone: 708-346-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019023283
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: