Healthcare Provider Details

I. General information

NPI: 1104838002
Provider Name (Legal Business Name): KESANET T GEBREKIDAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5359 W FULLERTON AVE
CHICAGO IL
60639-1450
US

IV. Provider business mailing address

2303 CENTRAL ST APT 1W
EVANSTON IL
60201-5728
US

V. Phone/Fax

Practice location:
  • Phone: 773-637-7053
  • Fax:
Mailing address:
  • Phone: 847-864-4914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: