Provider Demographics
NPI:1649464678
Name:FRITSCH, KENNETH GERARD (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GERARD
Last Name:FRITSCH
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 1:15030 S RAVINIA AVE
Mailing Address - Street 2:SUITE #36
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3256
Mailing Address - Country:US
Mailing Address - Phone:708-403-4766
Mailing Address - Fax:
Practice Address - Street 1:15030 S RAVINIA AVE
Practice Address - Street 2:SUITE #36
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3256
Practice Address - Country:US
Practice Address - Phone:708-403-4766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice