Healthcare Provider Details

I. General information

NPI: 1205842721
Provider Name (Legal Business Name): KENNETH ERIC ANTONOFF D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6215 E STATE ST
ROCKFORD IL
61108-2514
US

IV. Provider business mailing address

6215 E STATE ST
ROCKFORD IL
61108-2514
US

V. Phone/Fax

Practice location:
  • Phone: 414-340-1844
  • Fax:
Mailing address:
  • Phone: 414-340-1844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019026049
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: