MEDICARE: DR. JASON KENNETH KORKUS D.D.S.

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427049576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON KENNETH KORKUS D.D.S.

Provider Business Mailing Address
First Line	:	250 W SCOTT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-1854
Country	:	US
Telephone Number	:	312-587-7541
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 S CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2405
Country	:	US
Telephone Number	:	773-484-1201
Fax Number	:	773-484-1205

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	07/09/2007

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