Healthcare Provider Details

I. General information

NPI: 1023943859
Provider Name (Legal Business Name): COLE ANTHONY KALLENBACH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E DEAN ST
VIRDEN IL
62690-1446
US

IV. Provider business mailing address

730 W DEAN ST
VIRDEN IL
62690-1357
US

V. Phone/Fax

Practice location:
  • Phone: 217-965-3032
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.037203
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: