Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 019.030217 | IL |
Y | 1223D0001X | Dental Public Health | 019.030217 | IL |
NPI | 1417330556 |
---|---|
Provider Name | Samantha Kufta |
First Address | West Chicago, IL 60185-2436 |
Second Address | Chicago, IL 60653-3030 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2015 |
Last Update Date | 07/07/2015 |