Provider Demographics
NPI:1386374791
Name:MALZENSKI, CHARLIE
Entity type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:
Last Name:MALZENSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:MALZENSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3000 WHITE OAK LN
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2500
Mailing Address - Country:US
Mailing Address - Phone:630-209-3680
Mailing Address - Fax:
Practice Address - Street 1:342 RANDALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-2261
Practice Address - Country:US
Practice Address - Phone:630-883-8146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0336861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice