Provider Demographics
NPI:1619983244
Name:PESKIN, KENNETH HOWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:HOWARD
Last Name:PESKIN
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 1:4711 GOLF RD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1224
Mailing Address - Country:US
Mailing Address - Phone:847-676-4590
Mailing Address - Fax:847-676-4695
Practice Address - Street 1:4711 GOLF RD
Practice Address - Street 2:SUITE 408
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1224
Practice Address - Country:US
Practice Address - Phone:847-676-4590
Practice Address - Fax:847-676-4695
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU60578Medicare UPIN
ILL85942Medicare ID - Type Unspecified