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General NPI Number Information
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NPI Number | 1669865135
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Entity Type | Organization
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Legal Business Name | NAPERVILLE DENTAL GROUP
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Dates
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Enumeration Date | 03/09/2015
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Last Update Date | 03/09/2015
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Provider Practice Location Address
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Address Line | 1020 E OGDEN AVE SUITE 308
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City | NAPERVILLE
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State | IL
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Zip | 60563-8609
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Country | US
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Telephone | 630-527-0544
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Fax | 630-527-2433
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Provider Business Mailing Address
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Address Line | 1020 E OGDEN AVE SUITE 308
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City | NAPERVILLE
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State | IL
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Zip | 60563-8609
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Country | US
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Telephone | 630-527-0544
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Fax | 630-527-2433
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Authorized Official
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Title or Position | PRESIDENT/BUSINESS OWNER
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Name | DR. KENNETH R. PICKETT
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Credential | D.D.S.
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Telephone | 630-527-0544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.017904
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.029826
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.029826
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 021.001252
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License Number State | IL
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Taxonomy #5
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.017904
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License Number State | IL
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