Healthcare Provider Details

I. General information

NPI: 1538851670
Provider Name (Legal Business Name): KAORY GOMEZ-CALZADA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N ALPINE RD
ROCKFORD IL
61107-2262
US

IV. Provider business mailing address

1125 CANTERFIELD PKWY W
WEST DUNDEE IL
60118-9014
US

V. Phone/Fax

Practice location:
  • Phone: 815-397-4280
  • Fax:
Mailing address:
  • Phone: 414-581-6379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019034333
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: