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NPI Code Detail

MEDICARE: DR. KESANET T GEBREKIDAN DDS

MEDICARE: DR. KESANET T GEBREKIDAN DDS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentistIL

General Provider Information

NPI Number : 1104838002
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KESANET T GEBREKIDAN DDS
Provider Business Mailing Address
First Line : 2303 CENTRAL ST APT 1W
Second Line :
City : EVANSTON
State : IL
Zip : 60201-5728
Country : US
Telephone Number : 847-864-4914
Fax Number :
Provider Business Practice Location Address
First Line : 5359 W FULLERTON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60639-1450
Country : US
Telephone Number : 773-637-7053
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/12/2006
Last Update Date : 07/08/2007

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