Healthcare Provider Details

I. General information

NPI: 1356225973
Provider Name (Legal Business Name): KENNY A ROBLES GONZALEZ DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3253 S HARLEM AVE UNIT 1C
BERWYN IL
60402-2996
US

IV. Provider business mailing address

3253 S HARLEM AVE UNIT 1C
BERWYN IL
60402-2996
US

V. Phone/Fax

Practice location:
  • Phone: 708-788-4444
  • Fax:
Mailing address:
  • Phone: 708-788-4444
  • Fax: 708-788-4474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNY A ROBLES GONZALEZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 708-788-4444