Provider Demographics
NPI:1962621763
Name:EICHHOLZ, KENNETH L JR (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:EICHHOLZ
Suffix:JR
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 1:624 TERRA WEST DR
Mailing Address - Street 2:SUITE #1
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4595
Mailing Address - Country:US
Mailing Address - Phone:815-235-7165
Mailing Address - Fax:815-235-4870
Practice Address - Street 1:624 TERRA WEST DR
Practice Address - Street 2:SUITE #1
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4595
Practice Address - Country:US
Practice Address - Phone:815-235-7165
Practice Address - Fax:815-235-4870
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190269831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice