Provider Demographics
NPI:1447349618
Name:KUSNOTO, BUDI (DDS, MS)
Entity type:Individual
Prefix:
First Name:BUDI
Middle Name:
Last Name:KUSNOTO
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 W POLK ST
Mailing Address - Street 2:SUITE 251
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2000
Mailing Address - Country:US
Mailing Address - Phone:312-804-8304
Mailing Address - Fax:312-873-3803
Practice Address - Street 1:842 W 31ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608
Practice Address - Country:US
Practice Address - Phone:312-804-8304
Practice Address - Fax:312-873-3803
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022824122300000X
IL0210021611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist