Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | IL |
NPI | 1396835583 |
---|---|
Provider Name | Dr. Kenneth C Pinkerton |
First Address | Belleville, IL 62223-1495 |
Second Address | Belleville, IL 62223-1495 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
80115934 | ILLINOIS BLUE SHIELD (01) | IL |
985218 | UNITED CONCORDIA (01) | |
U74818 | (02) |