Healthcare Provider Details

I. General information

NPI: 1346699766
Provider Name (Legal Business Name): LAURA KRABILL KHESHGI D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 W PERU ST
PRINCETON IL
61356-1946
US

IV. Provider business mailing address

475 W PERU ST
PRINCETON IL
61356-1946
US

V. Phone/Fax

Practice location:
  • Phone: 815-875-6449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.030657
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: