Healthcare Provider Details

I. General information

NPI: 1538836200
Provider Name (Legal Business Name): KARTIKI AGRAWAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 09/05/2021
Certification Date: 09/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2937 IL-178
NORTH UTICA IL
61373
US

IV. Provider business mailing address

23806 SPRINGS CT APT 103
PLAINFIELD IL
60585-2262
US

V. Phone/Fax

Practice location:
  • Phone: 815-993-3101
  • Fax:
Mailing address:
  • Phone: 551-216-9133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.33370
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: