=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710637988
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY JAMES CARRERAS-SIMONS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2022
-----------------------------------------------------
Last Update Date | 07/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 PEORIA ST
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61571-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-444-3811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 651 HARDING ROAD UNIT 204H
-----------------------------------------------------
City | MORTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.033584
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------