MEDICARE: KISS DENTAL 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	019.027916	IL
2	1223G0001X	General Practice Dentistry	019.017535	IL

General Provider Information

NPI Number	:	1558662106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KISS DENTAL PC

Provider Business Mailing Address
First Line	:	5841 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-5201
Country	:	US
Telephone Number	:	773-622-3454
Fax Number	:	773-622-0990

Provider Business Practice Location Address
First Line	:	5841 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-5201
Country	:	US
Telephone Number	:	773-622-3454
Fax Number	:	773-622-0990

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHESTER PAUL KLOS
Credential	:	DDS
Telephone Number	:	773-622-3454

Provider Enumeration Date	:	11/13/2010
Last Update Date	:	04/01/2015

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Practice Location Address:

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Directions to “KISS DENTAL PC ” Practice Location

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