=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215010582
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KASPERS ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 07/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1873 SHERMER RD
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-564-9115
-----------------------------------------------------
Fax | 847-564-2097
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1873 SHERMER RD
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-564-9115
-----------------------------------------------------
Fax | 847-564-2097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT LAWRENCE KASPERS
-----------------------------------------------------
Credential | DDS MS
-----------------------------------------------------
Telephone | 847-564-9115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 021001187
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019018515
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------