Healthcare Provider Details

I. General information

NPI: 1861837973
Provider Name (Legal Business Name): KUNNEL DENTAL CENTER P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9933 LAWLER AVE #401
SKOKIE IL
60077-3703
US

IV. Provider business mailing address

9933 LAWLER AVE #401
SKOKIE IL
60077-3703
US

V. Phone/Fax

Practice location:
  • Phone: 847-675-7090
  • Fax:
Mailing address:
  • Phone: 847-675-7090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number019024836
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number019024293
License Number StateIL

VIII. Authorized Official

Name: DR. JESSIE KUNNEL
Title or Position: PRESIDENT
Credential: DDS
Phone: 847-675-5590