MEDICARE: J. MICHAEL KRISKO DDS, LTD.

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	122300000X	Dentist		IL

General Provider Information

NPI Number	:	1841298817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J. MICHAEL KRISKO DDS, LTD.

Provider Business Mailing Address
First Line	:	508 BARRY TURN
Second Line	:
City	:	MANTENO
State	:	IL
Zip	:	60950-1657
Country	:	US
Telephone Number	:	815-468-1930
Fax Number	:	815-939-0920

Provider Business Practice Location Address
First Line	:	401 N WALL ST
Second Line	:	STE 206
City	:	KANKAKEE
State	:	IL
Zip	:	60901-2934
Country	:	US
Telephone Number	:	815-468-1930
Fax Number	:	815-939-0920

Authorized Official
Title or Position	:	PRESIDENT
Name	:	J. MICHAEL KRISKO
Credential	:	D.D.S.
Telephone Number	:	815-468-1930

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	08/22/2020

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