Provider Demographics
NPI:1184939076
Name:FASANYA, KEHINDE JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:KEHINDE
Middle Name:JOHN
Last Name:FASANYA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W ERIE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-6920
Mailing Address - Country:US
Mailing Address - Phone:920-838-1649
Mailing Address - Fax:312-944-9499
Practice Address - Street 1:6215 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2514
Practice Address - Country:US
Practice Address - Phone:920-838-1649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028443122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist