Provider Demographics
NPI:1871455832
Name:KEDZIE DENTISTRY LLC
Entity type:Organization
Organization Name:KEDZIE DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PRASANTH
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMMARAJU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-247-7216
Mailing Address - Street 1:5430 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-2620
Mailing Address - Country:US
Mailing Address - Phone:773-295-2523
Mailing Address - Fax:
Practice Address - Street 1:5430 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-2620
Practice Address - Country:US
Practice Address - Phone:773-295-2523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-28
Last Update Date:2025-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty