Healthcare Provider Details

I. General information

NPI: 1598149288
Provider Name (Legal Business Name): ASHOK KOTHARI DDS, MDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 W 55TH ST
COUNTRYSIDE IL
60525-6613
US

IV. Provider business mailing address

919 W. 55TH STREET
COUNTRYSIDE IL
60525
US

V. Phone/Fax

Practice location:
  • Phone: 708-352-1658
  • Fax: 708-352-1683
Mailing address:
  • Phone: 708-352-1658
  • Fax: 708-352-1683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0190190008
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021001268
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: