Provider Demographics
NPI:1336295708
Name:ARRIETA, KEN (DDS)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:ARRIETA
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 1:2241 THEODORE
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403
Mailing Address - Country:US
Mailing Address - Phone:815-741-1700
Mailing Address - Fax:815-741-8511
Practice Address - Street 1:2241 THEODORE
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403
Practice Address - Country:US
Practice Address - Phone:815-741-1700
Practice Address - Fax:815-741-8511
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics