=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134625031
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAPIL KELLA DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2018
-----------------------------------------------------
Last Update Date | 04/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5505 N CLARK ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-714-3142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1630 CHICAGO AVE APT 1302
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-714-3142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | KAPIL KELLA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 989-714-3142
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.029212
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------