=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437673175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. JOANN C KANIA DDS LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2017
-----------------------------------------------------
Last Update Date | 08/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6019 W BELMONT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60634-5116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-745-7188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2322 N MAPLEWOOD AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-3129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-505-5987
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOANN CAROL KANIA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 312-505-5987
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------