Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 136000200 | IL |
NPI | 1093183907 |
---|---|
Provider Name | Dr. Evelina Kratunova |
First Address | Chicago, IL 60612-7210 |
Second Address | Chicago, IL 60612-7210 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/09/2015 |
Last Update Date | 09/09/2015 |