Provider Demographics
NPI:1760054811
Name:SONRISA CAPITATION CCHC PROFESSIONAL CORPORATION SONRISA FAMILY DENTAL
Entity Type:Organization
Organization Name:SONRISA CAPITATION CCHC PROFESSIONAL CORPORATION SONRISA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:KORKUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-722-6460
Mailing Address - Street 1:3520 S MORGAN ST STE 207-208
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1533
Mailing Address - Country:US
Mailing Address - Phone:312-722-6460
Mailing Address - Fax:312-893-2275
Practice Address - Street 1:9718 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1007
Practice Address - Country:US
Practice Address - Phone:872-703-3032
Practice Address - Fax:312-893-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty