Provider Demographics
NPI:1104047638
Name:WOSTL, ERIC ROY (DDS)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:ROY
Last Name:WOSTL
Suffix:
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 1:209 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5320
Mailing Address - Country:US
Mailing Address - Phone:630-668-1455
Mailing Address - Fax:630-668-4230
Practice Address - Street 1:209 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5320
Practice Address - Country:US
Practice Address - Phone:630-668-1455
Practice Address - Fax:630-668-4230
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice