1790906139 NPI number — KENNETH D. MEISS D.M.D. LTD.

Table of content: (NPI 1790906139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790906139 NPI number — KENNETH D. MEISS D.M.D. LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH D. MEISS D.M.D. LTD.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790906139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 W GLEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-4879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-682-9802
Provider Business Mailing Address Fax Number:
309-682-9809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 W GLEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-4879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-682-9802
Provider Business Practice Location Address Fax Number:
309-682-9809
Provider Enumeration Date:
05/02/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MEISS
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
DELAINE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-682-9802

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  019-024524 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)