Provider Demographics
NPI:1114090750
Name:KRYSTYNA WAGENHEJM CIESIELSKI DDS PC
Entity type:Organization
Organization Name:KRYSTYNA WAGENHEJM CIESIELSKI DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRYSTYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGENEHJM-CIESIELSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-581-9400
Mailing Address - Street 1:7900 N MILWAUKEE AVE
Mailing Address - Street 2:STE 2-21B
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3159
Mailing Address - Country:US
Mailing Address - Phone:847-581-9400
Mailing Address - Fax:847-581-9044
Practice Address - Street 1:7900 N MILWAUKEE AVE
Practice Address - Street 2:STE 2-21B
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3159
Practice Address - Country:US
Practice Address - Phone:847-581-9400
Practice Address - Fax:847-581-9044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210021821223E0200X
IL0210015191223P0300X
IL019024460122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty