Healthcare Provider Details

I. General information

NPI: 1053988204
Provider Name (Legal Business Name): SONRISA CCHC CAPITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9718 S HALSTED ST
CHICAGO IL
60628-1007
US

IV. Provider business mailing address

3520 S MORGAN ST STE 207-208
CHICAGO IL
60609-1533
US

V. Phone/Fax

Practice location:
  • Phone: 872-703-3032
  • Fax: 312-893-2275
Mailing address:
  • Phone: 312-722-6460
  • Fax: 312-893-2275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JASON K KORKUS
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 312-722-6460