Provider Demographics
NPI:1205450509
Name:LAGESSE, KAITLYN (DMD)
Entity type:Individual
Prefix:DR
First Name:KAITLYN
Middle Name:
Last Name:LAGESSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 S PRAIRIE AVE APT 1804
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4345
Mailing Address - Country:US
Mailing Address - Phone:773-909-9291
Mailing Address - Fax:
Practice Address - Street 1:3600 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5304
Practice Address - Country:US
Practice Address - Phone:773-433-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032623122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019.032623OtherSTATE OF ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION