Provider Demographics
NPI:1396884599
Name:PICKETT, KENNETH R (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:PICKETT
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 1:1020 E OGDEN AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8609
Mailing Address - Country:US
Mailing Address - Phone:630-527-0544
Mailing Address - Fax:630-527-2433
Practice Address - Street 1:1020 E OGDEN AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8609
Practice Address - Country:US
Practice Address - Phone:630-527-0544
Practice Address - Fax:630-527-2433
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223P0300XDental ProvidersDentistPeriodontics