Provider Demographics
NPI:1366772287
Name:RAKSTANG, JONATHAN KENNETH (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:KENNETH
Last Name:RAKSTANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 S CLARK ST APT 1004
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1548
Mailing Address - Country:US
Mailing Address - Phone:303-669-8175
Mailing Address - Fax:
Practice Address - Street 1:7820 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-1584
Practice Address - Country:US
Practice Address - Phone:708-391-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8923122300000X
AR3740122300000X
IL019.0328701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No122300000XDental ProvidersDentist