Provider Demographics
NPI:1902122401
Name:KAY, CHARLES JONATHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JONATHAN
Last Name:KAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E. JEFFREY
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-7168
Mailing Address - Country:US
Mailing Address - Phone:815-939-8356
Mailing Address - Fax:
Practice Address - Street 1:100 E. JEFFREY
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-7168
Practice Address - Country:US
Practice Address - Phone:815-939-8356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-019642122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist