Provider Demographics
NPI:1225721129
Name:STAHLIN, KENDYLL KEENAN (DMD)
Entity Type:Individual
Prefix:
First Name:KENDYLL
Middle Name:KEENAN
Last Name:STAHLIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 N ADA ST APT 514
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1542
Mailing Address - Country:US
Mailing Address - Phone:732-684-4937
Mailing Address - Fax:
Practice Address - Street 1:3250 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2729
Practice Address - Country:US
Practice Address - Phone:773-232-5383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0342231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice