Provider Demographics
NPI:1235236811
Name:EADES, KENNETH LUKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LUKE
Last Name:EADES
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 1:2810 S WALNUT STREET PIKE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8403
Mailing Address - Country:US
Mailing Address - Phone:812-336-2600
Mailing Address - Fax:812-336-1090
Practice Address - Street 1:2810 S WALNUT STREET PIKE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8403
Practice Address - Country:US
Practice Address - Phone:812-336-2600
Practice Address - Fax:812-336-1090
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009011A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist