Healthcare Provider Details

I. General information

NPI: 1811155096
Provider Name (Legal Business Name): H JOHNNY IBRAHIM KUTTAB D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2008
Last Update Date: 05/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3012 W FULLERTON AVE
CHICAGO IL
60647-2808
US

IV. Provider business mailing address

1090 KINGSDALE RD
HOFFMAN ESTATES IL
60169-2377
US

V. Phone/Fax

Practice location:
  • Phone: 773-384-3500
  • Fax:
Mailing address:
  • Phone: 847-971-8847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number019027640
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: