MEDICARE: DR. KENNY MATEE GOMOLPLITINANT D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	319019495	IL
2	122300000X	Dentist	019030276	IL

General Provider Information

NPI Number	:	1184008799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNY MATEE GOMOLPLITINANT D.M.D.

Provider Business Mailing Address
First Line	:	413 W SAINT CHARLES RD
Second Line	:
City	:	VILLA PARK
State	:	IL
Zip	:	60181-2432
Country	:	US
Telephone Number	:	630-629-3120
Fax Number	:

Provider Business Practice Location Address
First Line	:	413 W SAINT CHARLES RD
Second Line	:
City	:	VILLA PARK
State	:	IL
Zip	:	60181-2432
Country	:	US
Telephone Number	:	630-629-3120
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2015
Last Update Date	:	07/07/2021

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