Provider Demographics
NPI:1487004081
Name:KOWALESIK, KAREN ANN (DMD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ANN
Last Name:KOWALESIK
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 1:9719 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3614
Mailing Address - Country:US
Mailing Address - Phone:708-423-1417
Mailing Address - Fax:
Practice Address - Street 1:9719 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3614
Practice Address - Country:US
Practice Address - Phone:708-423-1417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030709122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist