Healthcare Provider Details

I. General information

NPI: 1508964057
Provider Name (Legal Business Name): MARTIN PETER KORNAK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 E BURLINGTON ST
RIVERSIDE IL
60546-2118
US

IV. Provider business mailing address

84 E BURLINGTON ST
RIVERSIDE IL
60546-2118
US

V. Phone/Fax

Practice location:
  • Phone: 708-447-9299
  • Fax: 708-447-9322
Mailing address:
  • Phone: 708-447-9299
  • Fax: 708-447-9322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: