Healthcare Provider Details

I. General information

NPI: 1508908393
Provider Name (Legal Business Name): KLEIN & COOK ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 LINCOLNSHIRE
MT VERNON IL
62864
US

IV. Provider business mailing address

4210 LINCOLNSHIRE
MT VERNON IL
62864
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-7747
  • Fax: 618-244-7551
Mailing address:
  • Phone: 618-244-7747
  • Fax: 618-244-7551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. CHRISTOPHER KENNEDY KLEIN
Title or Position: CO OWNER PRESIDENT
Credential: DMD MS
Phone: 618-244-7747