Healthcare Provider Details

I. General information

NPI: 1316023989
Provider Name (Legal Business Name): KENNETH S. HAUSER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5432 W DEVON AVE SECOND FLOOR
CHICAGO IL
60646-4106
US

IV. Provider business mailing address

5432 W DEVON AVE SECOND FLOOR
CHICAGO IL
60646-4106
US

V. Phone/Fax

Practice location:
  • Phone: 773-775-0810
  • Fax: 773-775-0944
Mailing address:
  • Phone: 773-775-0810
  • Fax: 773-775-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: