MEDICARE: KAPIL KELLA DDS PC

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
1	1223G0001X	General Practice Dentistry	019.029212	IL

General Provider Information

NPI Number	:	1134625031
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAPIL KELLA DDS PC

Provider Business Mailing Address
First Line	:	1630 CHICAGO AVE APT 1302
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-4593
Country	:	US
Telephone Number	:	989-714-3142
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1213
Country	:	US
Telephone Number	:	989-714-3142
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	KAPIL KELLA
Credential	:	DDS
Telephone Number	:	989-714-3142

Provider Enumeration Date	:	04/01/2018
Last Update Date	:	04/01/2018

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