Provider Demographics
NPI:1922211614
Name:KENNETH MICHAEL FRIED
Entity Type:Organization
Organization Name:KENNETH MICHAEL FRIED
Other - Org Name:UNITED DENTAL CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:FRIED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-646-6262
Mailing Address - Street 1:1332 119TH ST.
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:IN
Mailing Address - Zip Code:46394
Mailing Address - Country:US
Mailing Address - Phone:219-659-4900
Mailing Address - Fax:
Practice Address - Street 1:1332 119TH ST
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:IN
Practice Address - Zip Code:46394-1631
Practice Address - Country:US
Practice Address - Phone:219-659-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120091741223G0001X
IL0190171901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty