Provider Demographics
NPI:1538512884
Name:SPROUT PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:SPROUT PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:I
Authorized Official - Last Name:KUTTAB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-377-5658
Mailing Address - Street 1:6036 N. NORTHWEST HIGWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631
Mailing Address - Country:US
Mailing Address - Phone:773-377-5658
Mailing Address - Fax:773-409-4663
Practice Address - Street 1:6036 NORTH NORTHWEST HIGHWAY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631
Practice Address - Country:US
Practice Address - Phone:773-377-5658
Practice Address - Fax:773-409-4663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021002373122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty