Provider Demographics
NPI:1447642384
Name:KEVIN K SCHULTZ, DDS, PC
Entity type:Organization
Organization Name:KEVIN K SCHULTZ, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:KELSO
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-663-1721
Mailing Address - Street 1:10 HEARTLAND DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7741
Mailing Address - Country:US
Mailing Address - Phone:309-663-1721
Mailing Address - Fax:
Practice Address - Street 1:10 HEARTLAND DR
Practice Address - Street 2:SUITE C
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7741
Practice Address - Country:US
Practice Address - Phone:309-663-1721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.018656261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental