Provider Demographics
NPI:1124606538
Name:GURUKKAL, JANANI KOTESHWARAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JANANI
Middle Name:KOTESHWARAN
Last Name:GURUKKAL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 S MICHIGAN AVE APT 2808
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3527
Mailing Address - Country:US
Mailing Address - Phone:615-852-0170
Mailing Address - Fax:
Practice Address - Street 1:61 W 144TH ST
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:IL
Practice Address - Zip Code:60827-2850
Practice Address - Country:US
Practice Address - Phone:708-419-2204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0339191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program