Provider Demographics
NPI:1942490149
Name:HUMBOLDT COMMUNITY DENTAL PC
Entity Type:Organization
Organization Name:HUMBOLDT COMMUNITY DENTAL PC
Other - Org Name:SONRISA FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:KORKUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-772-9200
Mailing Address - Street 1:1044 N MOZART ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2789
Mailing Address - Country:US
Mailing Address - Phone:773-772-9200
Mailing Address - Fax:773-772-9203
Practice Address - Street 1:1044 N MOZART ST
Practice Address - Street 2:SUITE 401
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2789
Practice Address - Country:US
Practice Address - Phone:773-772-9200
Practice Address - Fax:773-772-9203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL163914Medicaid