Healthcare Provider Details

I. General information

NPI: 1558662106
Provider Name (Legal Business Name): KISS DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2010
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 W BELMONT AVE
CHICAGO IL
60634-5201
US

IV. Provider business mailing address

5841 W BELMONT AVE
CHICAGO IL
60634-5201
US

V. Phone/Fax

Practice location:
  • Phone: 773-622-3454
  • Fax: 773-622-0990
Mailing address:
  • Phone: 773-622-3454
  • Fax: 773-622-0990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.027916
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.017535
License Number StateIL

VIII. Authorized Official

Name: DR. CHESTER PAUL KLOS
Title or Position: PRESIDENT
Credential: DDS
Phone: 773-622-3454