Healthcare Provider Details

I. General information

NPI: 1376651232
Provider Name (Legal Business Name): LISA KATHERINE KEARNEY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4751 N KEDZIE AVE 2ND FLOOR
CHICAGO IL
60625
US

IV. Provider business mailing address

2710 N FAIRFIELD AVE APT 2S
CHICAGO IL
60647-1863
US

V. Phone/Fax

Practice location:
  • Phone: 312-432-4360
  • Fax:
Mailing address:
  • Phone: 773-292-0655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019026123
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-026123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: