Provider Demographics
NPI:1417673310
Name:ANTONOFF DENTAL, LLC
Entity Type:Organization
Organization Name:ANTONOFF DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTISTS
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-698-4324
Mailing Address - Street 1:6803 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-1321
Mailing Address - Country:US
Mailing Address - Phone:262-484-4356
Mailing Address - Fax:
Practice Address - Street 1:6803 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-1321
Practice Address - Country:US
Practice Address - Phone:262-484-4356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental