Provider Demographics
NPI:1710034574
Name:KRISKO, J MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:MICHAEL
Last Name:KRISKO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N WALL ST
Mailing Address - Street 2:STE 206
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2934
Mailing Address - Country:US
Mailing Address - Phone:815-939-2012
Mailing Address - Fax:815-939-0920
Practice Address - Street 1:401 N WALL ST
Practice Address - Street 2:STE 206
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2934
Practice Address - Country:US
Practice Address - Phone:815-939-2012
Practice Address - Fax:815-939-0920
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice