Provider Demographics
NPI:1427114115
Name:WIERSEMA, CHAD RYAN (DDS)
Entity type:Individual
Prefix:MR
First Name:CHAD
Middle Name:RYAN
Last Name:WIERSEMA
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 1:18130 HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2507
Mailing Address - Country:US
Mailing Address - Phone:708-799-2550
Mailing Address - Fax:
Practice Address - Street 1:18130 HALSTED ST
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2507
Practice Address - Country:US
Practice Address - Phone:708-799-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026244122300000X
IN12010886A122300000X
IL0210021951223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist