Provider Demographics
NPI:1558662106
Name:KISS DENTAL PC
Entity Type:Organization
Organization Name:KISS DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-622-3454
Mailing Address - Street 1:5841 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-5201
Mailing Address - Country:US
Mailing Address - Phone:773-622-3454
Mailing Address - Fax:773-622-0990
Practice Address - Street 1:5841 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-5201
Practice Address - Country:US
Practice Address - Phone:773-622-3454
Practice Address - Fax:773-622-0990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-13
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0175351223G0001X
IL019.0279161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty