Provider Demographics
NPI:1629070743
Name:KREBS, KENNETH A (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:KREBS
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 1:30 N MICHIGAN AVE
Mailing Address - Street 2:STE 822
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3805
Mailing Address - Country:US
Mailing Address - Phone:312-332-3937
Mailing Address - Fax:312-332-3929
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:STE 822
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3805
Practice Address - Country:US
Practice Address - Phone:312-332-3937
Practice Address - Fax:312-332-3929
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-013265122300000X
IL21-0006641223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21-000664OtherSPECIALTY LICENSE
IL19-013265OtherDENTAL LICENSE