Healthcare Provider Details

I. General information

NPI: 1104086008
Provider Name (Legal Business Name): KOTIS AND KANELLOS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9206 S COMMERCIAL AVE
CHICAGO IL
60617-4508
US

IV. Provider business mailing address

9206 S COMMERCIAL AVE
CHICAGO IL
60617-4508
US

V. Phone/Fax

Practice location:
  • Phone: 773-978-4447
  • Fax: 773-978-7662
Mailing address:
  • Phone: 773-978-4447
  • Fax: 773-978-7662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number060.005824
License Number StateIL

VIII. Authorized Official

Name: DR. JAMES P KANELLOS
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 773-978-4447