Provider Demographics
NPI:1104838002
Name:GEBREKIDAN, KESANET T (DDS)
Entity Type:Individual
Prefix:DR
First Name:KESANET
Middle Name:T
Last Name:GEBREKIDAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 CENTRAL ST APT 1W
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5728
Mailing Address - Country:US
Mailing Address - Phone:847-864-4914
Mailing Address - Fax:
Practice Address - Street 1:5359 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1450
Practice Address - Country:US
Practice Address - Phone:773-637-7053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist