Provider Demographics
NPI:1538288022
Name:KAUFMAN, KENNETH WILLIAM (DDS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:KAUFMAN
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 1:4600 WEST JAMES STREET
Mailing Address - Street 2:
Mailing Address - City:MT MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:61054-1640
Mailing Address - Country:US
Mailing Address - Phone:815-734-6668
Mailing Address - Fax:
Practice Address - Street 1:105 E LINCOLN STREET
Practice Address - Street 2:
Practice Address - City:MT MORRIS
Practice Address - State:IL
Practice Address - Zip Code:61054-1640
Practice Address - Country:US
Practice Address - Phone:815-734-4195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice