Healthcare Provider Details

I. General information

NPI: 1811335730
Provider Name (Legal Business Name): YASMIN VANESSA KOCMOND D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 OAKTON ST
PARK RIDGE IL
60068-1958
US

IV. Provider business mailing address

769 N KENILWORTH AVE
GLEN ELLYN IL
60137-3850
US

V. Phone/Fax

Practice location:
  • Phone: 847-292-6540
  • Fax: 847-292-0771
Mailing address:
  • Phone: 847-702-9577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019029429
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: