Provider Demographics
NPI:1851960728
Name:KMG DENTAL SERVICES, P.C.
Entity Type:Organization
Organization Name:KMG DENTAL SERVICES, P.C.
Other - Org Name:HANDCRAFTED SMILES AH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:MATEE
Authorized Official - Last Name:GOMOLPLITINANT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-357-3899
Mailing Address - Street 1:1610 W FULLERTON AVE UNIT 203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-9048
Mailing Address - Country:US
Mailing Address - Phone:818-983-5066
Mailing Address - Fax:
Practice Address - Street 1:2101 S ARLINGTON HEIGHTS RD STE 117
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-4197
Practice Address - Country:US
Practice Address - Phone:847-357-3899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty