Healthcare Provider Details

I. General information

NPI: 1124957584
Provider Name (Legal Business Name): SHOHRAT KOCHOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 WATERVIEW CIR APT 4
VERNON HILLS IL
60061-2500
US

IV. Provider business mailing address

810 WATERVIEW CIR APT 4
VERNON HILLS IL
60061-2500
US

V. Phone/Fax

Practice location:
  • Phone: 224-266-8311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: