Provider Demographics
NPI:1619565405
Name:KANSARA, KAJOL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAJOL
Middle Name:
Last Name:KANSARA
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 1:671 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-5801
Mailing Address - Country:US
Mailing Address - Phone:248-943-8127
Mailing Address - Fax:
Practice Address - Street 1:1639 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-1520
Practice Address - Country:US
Practice Address - Phone:708-477-6717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032962122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist