Provider Demographics
NPI:1326120445
Name:RENNER, KATHLEEN S (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:S
Last Name:RENNER
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 1:4201 WILLIAMSON PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6740
Mailing Address - Country:US
Mailing Address - Phone:618-244-5120
Mailing Address - Fax:
Practice Address - Street 1:4201 WILLIAMSON PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6740
Practice Address - Country:US
Practice Address - Phone:618-244-5120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice