Provider Demographics
NPI:1326696337
Name:MACZKO, KELSEY MARIE (DMD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:MACZKO
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 1:1112 E CENTRAL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3288
Mailing Address - Country:US
Mailing Address - Phone:847-398-1334
Mailing Address - Fax:847-398-3096
Practice Address - Street 1:1112 E CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-3288
Practice Address - Country:US
Practice Address - Phone:847-398-1334
Practice Address - Fax:847-398-3096
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL018.032107122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist