Provider Demographics
NPI:1528691508
Name:JAY A WYGODNY DMD PC
Entity type:Organization
Organization Name:JAY A WYGODNY DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WYGODNY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-265-4420
Mailing Address - Street 1:2592 E GRAND AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5915
Mailing Address - Country:US
Mailing Address - Phone:847-265-4420
Mailing Address - Fax:847-265-4429
Practice Address - Street 1:2592 E GRAND AVE STE 102
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-5915
Practice Address - Country:US
Practice Address - Phone:847-265-4420
Practice Address - Fax:847-265-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies