Healthcare Provider Details

I. General information

NPI: 1669470217
Provider Name (Legal Business Name): MICHAEL A. KRELL D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W PETERSON AVE SUITE 128
CHICAGO IL
60646-6074
US

IV. Provider business mailing address

4200 W PETERSON AVE SUITE 128
CHICAGO IL
60646-6074
US

V. Phone/Fax

Practice location:
  • Phone: 773-777-6332
  • Fax: 773-777-6318
Mailing address:
  • Phone: 773-777-6332
  • Fax: 773-777-6318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: