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General NPI Number Information
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NPI Number | 1821962119
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Entity Type | Individual
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Provider Name | IVO KOMORNICKI
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Gender |
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Dates
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Enumeration Date | 10/01/2025
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Last Update Date | 10/01/2025
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Provider Practice Location Address
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Address Line | 805 W SPRINGFIELD AVE
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City | CHAMPAIGN
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State | IL
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Zip | 61820
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Country | US
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Telephone | 217-352-5088
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Fax |
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Provider Business Mailing Address
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Address Line | 805 W SPRINGFIELD AVE.
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City | CHAMPAIGN
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State | IL
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Zip | 61820
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.036319
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License Number State | IL
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