Provider Demographics
NPI:1528180916
Name:KILLINO, KENNETH C (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:KILLINO
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 1:520 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1542
Mailing Address - Country:US
Mailing Address - Phone:570-457-7855
Mailing Address - Fax:570-457-3051
Practice Address - Street 1:520 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1542
Practice Address - Country:US
Practice Address - Phone:570-457-7855
Practice Address - Fax:570-457-3051
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-027075-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice