Provider Demographics
NPI:1194566406
Name:PONNUSAMY, KAYATHRI (DMD)
Entity type:Individual
Prefix:DR
First Name:KAYATHRI
Middle Name:
Last Name:PONNUSAMY
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 1:2389 RIVER HILLS LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-4938
Mailing Address - Country:US
Mailing Address - Phone:248-704-5780
Mailing Address - Fax:
Practice Address - Street 1:11137 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-7428
Practice Address - Country:US
Practice Address - Phone:815-277-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.035105122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist