Healthcare Provider Details

I. General information

NPI: 1770681223
Provider Name (Legal Business Name): MARTIN P KORNAK DDS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
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 State

VIII. Authorized Official

Name: DR. MARTIN PETER KORNAK
Title or Position: PRESIDENT
Credential: DDS
Phone: 708-447-9299