Healthcare Provider Details

I. General information

NPI: 1063220085
Provider Name (Legal Business Name): LYNN KHOLOKI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2861 83RD ST
DARIEN IL
60561-5612
US

IV. Provider business mailing address

50 YORKTOWN SHOPPING CTR UNIT 464
LOMBARD IL
60148-5649
US

V. Phone/Fax

Practice location:
  • Phone: 630-427-1800
  • Fax:
Mailing address:
  • Phone: 219-670-7759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12014601A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019034931
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: