Provider Demographics
NPI:1891964524
Name:EJSBRENNER, MARIA (DDS)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:EJSBRENNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:IWANICKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:5505 N MENARD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1221
Mailing Address - Country:US
Mailing Address - Phone:773-631-7070
Mailing Address - Fax:773-631-3770
Practice Address - Street 1:5505 N MENARD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1221
Practice Address - Country:US
Practice Address - Phone:773-631-7070
Practice Address - Fax:773-631-3770
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01921593122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist