Provider Demographics
NPI:1790906139
Name:KENNETH D. MEISS D.M.D. LTD.
Entity Type:Organization
Organization Name:KENNETH D. MEISS D.M.D. LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DELAINE
Authorized Official - Last Name:MEISS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:309-682-9802
Mailing Address - Street 1:910 W GLEN AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4879
Mailing Address - Country:US
Mailing Address - Phone:309-682-9802
Mailing Address - Fax:309-682-9809
Practice Address - Street 1:910 W GLEN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4879
Practice Address - Country:US
Practice Address - Phone:309-682-9802
Practice Address - Fax:309-682-9809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0245241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty