Provider Demographics
NPI:1366851610
Name:KENDALL, MICHAEL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:KENDALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 AVENUE OF THE CITIES
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4024
Mailing Address - Country:US
Mailing Address - Phone:309-755-1700
Mailing Address - Fax:
Practice Address - Street 1:401 AVENUE OF THE CITIES
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4024
Practice Address - Country:US
Practice Address - Phone:309-755-1700
Practice Address - Fax:309-755-1788
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA091341223G0001X
IL019.0298621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019.029862OtherSTATE LICENSE
IA09134OtherSTATE LIC