Healthcare Provider Details

I. General information

NPI: 1215010582
Provider Name (Legal Business Name): KASPERS ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1873 SHERMER RD
NORTHBROOK IL
60062
US

IV. Provider business mailing address

1873 SHERMER RD
NORTHBROOK IL
60062
US

V. Phone/Fax

Practice location:
  • Phone: 847-564-9115
  • Fax: 847-564-2097
Mailing address:
  • Phone: 847-564-9115
  • Fax: 847-564-2097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019018515
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021001187
License Number StateIL

VIII. Authorized Official

Name: DR. ROBERT LAWRENCE KASPERS
Title or Position: PRESIDENT
Credential: DDS MS
Phone: 847-564-9115