Healthcare Provider Details

I. General information

NPI: 1700060852
Provider Name (Legal Business Name): THOMAS KUKLA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 W PHILLIP RD
VERNON HILLS IL
60061-1799
US

IV. Provider business mailing address

10 W PHILLIP RD
VERNON HILLS IL
60061-1799
US

V. Phone/Fax

Practice location:
  • Phone: 847-680-7171
  • Fax: 847-680-4601
Mailing address:
  • Phone: 847-680-7171
  • Fax: 847-680-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019019252
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: