Provider Demographics
NPI:1699036624
Name:KENDALL FAMILY DENTAL
Entity Type:Organization
Organization Name:KENDALL FAMILY DENTAL
Other - Org Name:WORTH PALOS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WASOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-974-1319
Mailing Address - Street 1:7630 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-2302
Mailing Address - Country:US
Mailing Address - Phone:708-974-1319
Mailing Address - Fax:708-974-1671
Practice Address - Street 1:7630 W 111TH ST
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-2302
Practice Address - Country:US
Practice Address - Phone:708-974-1319
Practice Address - Fax:708-974-1671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190231371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty