Healthcare Provider Details

I. General information

NPI: 1912757667
Provider Name (Legal Business Name): SHOSHANA NINA KOTT DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5399 N MILWAUKEE AVE
CHICAGO IL
60630-1251
US

IV. Provider business mailing address

718 W CORNELIA AVE APT 2
CHICAGO IL
60657-2593
US

V. Phone/Fax

Practice location:
  • Phone: 773-763-1000
  • Fax:
Mailing address:
  • Phone: 301-646-9915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.035354
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: