Provider Demographics
NPI:1013283985
Name:DONALD C. KELLNER DDS-WOOD DALE PC
Entity Type:Organization
Organization Name:DONALD C. KELLNER DDS-WOOD DALE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:KELLNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-860-9100
Mailing Address - Street 1:333 NORTH WOOD DALE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191
Mailing Address - Country:US
Mailing Address - Phone:630-860-9100
Mailing Address - Fax:630-787-0662
Practice Address - Street 1:333 NORTH WOOD DALE RD
Practice Address - Street 2:SUITE A
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191
Practice Address - Country:US
Practice Address - Phone:630-860-9100
Practice Address - Fax:630-787-0662
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DONALD C. KELLNER DDS-WOOD DALE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019017632122300000X
IL019024905122300000X
IL019026111122300000X
IL019028094122300000X
IL021001200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019017632Medicaid