Provider Demographics
NPI:1053648865
Name:COLLEN, KENNETH JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAY
Last Name:COLLEN
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 1:1250 N MILL ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-6304
Mailing Address - Country:US
Mailing Address - Phone:630-355-7400
Mailing Address - Fax:630-355-7428
Practice Address - Street 1:1250 N MILL ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-6304
Practice Address - Country:US
Practice Address - Phone:630-355-7400
Practice Address - Fax:630-355-7428
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0167461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice