Provider Demographics
NPI:1821100371
Name:EATON, KATHY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:LYNN
Last Name:EATON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 W SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2933
Mailing Address - Country:US
Mailing Address - Phone:217-954-1347
Mailing Address - Fax:217-954-1361
Practice Address - Street 1:2106 W SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2933
Practice Address - Country:US
Practice Address - Phone:217-954-1347
Practice Address - Fax:217-954-1361
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025342122300000X
IL019.025342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9184608Medicaid