Provider Demographics
NPI:1669012860
Name:KJELD AAMODT DDS MS IL PC
Entity Type:Organization
Organization Name:KJELD AAMODT DDS MS IL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KJELD
Authorized Official - Middle Name:
Authorized Official - Last Name:AAMODT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:831-238-7285
Mailing Address - Street 1:999 SUTTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-6023
Mailing Address - Country:US
Mailing Address - Phone:831-238-7285
Mailing Address - Fax:
Practice Address - Street 1:11 E CEDAR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:415-653-3087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912250176Medicaid