Provider Demographics
NPI:1679642748
Name:KENNY, EDWARD JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHN
Last Name:KENNY
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 1:780 LEE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-6459
Mailing Address - Country:US
Mailing Address - Phone:847-827-1809
Mailing Address - Fax:847-827-9956
Practice Address - Street 1:780 LEE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-6459
Practice Address - Country:US
Practice Address - Phone:847-827-1809
Practice Address - Fax:847-827-9956
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist