Provider Demographics
NPI:1861434540
Name:HADDLE, KEVIN RAY (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RAY
Last Name:HADDLE
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2708
Mailing Address - Country:US
Mailing Address - Phone:630-232-9090
Mailing Address - Fax:630-232-9094
Practice Address - Street 1:426 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2708
Practice Address - Country:US
Practice Address - Phone:630-232-9090
Practice Address - Fax:630-232-9094
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH98071Medicare UPIN