=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902345762
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE JAMES HRESKO D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2017
-----------------------------------------------------
Last Update Date | 06/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7500 GRAND AVE STE 101
-----------------------------------------------------
City | GURNEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60031-1585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-272-9516
-----------------------------------------------------
Fax | 847-272-9551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1240 MEADOW RD STE 300
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-3679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-272-9516
-----------------------------------------------------
Fax | 816-272-9551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 6000023-15
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------