=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023827029
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNITED DENTAL SURGERY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2025
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8501 S CICERO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60652-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-668-9616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 LEXINGTON LN APT 112
-----------------------------------------------------
City | GLENVIEW
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60026-5936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-668-9616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. KEVIN KORDI
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 847-668-9616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------