Healthcare Provider Details

I. General information

NPI: 1730165168
Provider Name (Legal Business Name): CHESTER PAUL KLOS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/18/2005
Last Update Date: 07/08/2007
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:
Mailing address:
  • Phone: 773-622-3454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: