Healthcare Provider Details

I. General information

NPI: 1942490149
Provider Name (Legal Business Name): HUMBOLDT COMMUNITY DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 N MOZART ST SUITE 401
CHICAGO IL
60622-2789
US

IV. Provider business mailing address

1044 N MOZART ST SUITE 401
CHICAGO IL
60622-2789
US

V. Phone/Fax

Practice location:
  • Phone: 773-772-9200
  • Fax: 773-772-9203
Mailing address:
  • Phone: 773-772-9200
  • Fax: 773-772-9203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. JASON KORKUS
Title or Position: PRESIDENT
Credential: DDS
Phone: 773-772-9200