Provider Demographics
NPI:1205842721
Name:ANTONOFF, KENNETH ERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ERIC
Last Name:ANTONOFF
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 1:6803 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-1321
Mailing Address - Country:US
Mailing Address - Phone:262-484-4356
Mailing Address - Fax:262-484-4367
Practice Address - Street 1:6803 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-1321
Practice Address - Country:US
Practice Address - Phone:262-484-4356
Practice Address - Fax:262-484-4367
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6823-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL319014674OtherTAX ID