Healthcare Provider Details

I. General information

NPI: 1134453988
Provider Name (Legal Business Name): NICHOLAS R CUDNEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 W COLLEGE DR
PALOS HEIGHTS IL
60463-1155
US

IV. Provider business mailing address

7400 W COLLEGE DR
PALOS HEIGHTS IL
60463-1155
US

V. Phone/Fax

Practice location:
  • Phone: 708-448-8670
  • Fax: 708-448-8698
Mailing address:
  • Phone: 708-448-8670
  • Fax: 708-448-8698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019027476
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021.002532
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: