Provider Demographics
NPI:1962615393
Name:WASOWICZ, STEVEN DAVID (DDS)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:DAVID
Last Name:WASOWICZ
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 1:7630 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-2302
Mailing Address - Country:US
Mailing Address - Phone:708-974-1319
Mailing Address - Fax:708-974-4463
Practice Address - Street 1:7630 W 111TH ST
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-2302
Practice Address - Country:US
Practice Address - Phone:708-974-1319
Practice Address - Fax:708-974-4463
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0231371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice