Healthcare Provider Details

I. General information

NPI: 1174190599
Provider Name (Legal Business Name): JESUS ALEJANDRO ECHEZARRETA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 TOUHY AVE
SKOKIE IL
60077-3245
US

IV. Provider business mailing address

1120 35TH ST
DOWNERS GROVE IL
60515-1419
US

V. Phone/Fax

Practice location:
  • Phone: 847-807-7341
  • Fax:
Mailing address:
  • Phone: 773-307-1070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.033245
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: