Provider Demographics
NPI:1063625846
Name:WIECZOREK-TLALKA, MALGORZATA (DDS)
Entity type:Individual
Prefix:DR
First Name:MALGORZATA
Middle Name:
Last Name:WIECZOREK-TLALKA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400NORTHLAKESHOREDRIVE
Mailing Address - Street 2:APT.15'0'
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-6643
Mailing Address - Country:US
Mailing Address - Phone:312-482-9713
Mailing Address - Fax:509-267-2108
Practice Address - Street 1:WESTARCHER
Practice Address - Street 2:6941
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2330
Practice Address - Country:US
Practice Address - Phone:773-586-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice