Provider Demographics
NPI:1063636884
Name:O'BRIEN, KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:O'BRIEN
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 1:213 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-2418
Mailing Address - Country:US
Mailing Address - Phone:815-624-2626
Mailing Address - Fax:815-624-7821
Practice Address - Street 1:213 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-2418
Practice Address - Country:US
Practice Address - Phone:815-624-2626
Practice Address - Fax:815-624-7821
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice