Provider Demographics
NPI:1710102967
Name:KISHWAUKEE DENTAL ASSOCIATES, LTD.
Entity Type:Organization
Organization Name:KISHWAUKEE DENTAL ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SENDERAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDA
Authorized Official - Phone:815-758-4431
Mailing Address - Street 1:8 HEALTH SERVICES DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9647
Mailing Address - Country:US
Mailing Address - Phone:815-758-4431
Mailing Address - Fax:815-748-1169
Practice Address - Street 1:8 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9647
Practice Address - Country:US
Practice Address - Phone:815-758-4431
Practice Address - Fax:815-748-1169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty