Provider Demographics
NPI:1760729339
Name:RADKE, KERMIT (DMD)
Entity Type:Individual
Prefix:DR
First Name:KERMIT
Middle Name:
Last Name:RADKE
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 1:4165 OLD GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-2774
Mailing Address - Country:US
Mailing Address - Phone:847-623-4910
Mailing Address - Fax:847-623-6054
Practice Address - Street 1:4165 OLD GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2774
Practice Address - Country:US
Practice Address - Phone:847-623-4910
Practice Address - Fax:847-623-6054
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210016881223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics