Provider Demographics
NPI:1669865135
Name:NAPERVILLE DENTAL GROUP
Entity Type:Organization
Organization Name:NAPERVILLE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-527-0544
Mailing Address - Street 1:1020 E OGDEN AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8609
Mailing Address - Country:US
Mailing Address - Phone:630-527-0544
Mailing Address - Fax:630-527-2433
Practice Address - Street 1:1020 E OGDEN AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8609
Practice Address - Country:US
Practice Address - Phone:630-527-0544
Practice Address - Fax:630-527-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.017904122300000X, 1223G0001X
IL019.029826122300000X, 1223G0001X
IL021.0012521223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty