Provider Demographics
NPI:1972120400
Name:JANECKE, MARTIN (DMD PC)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:JANECKE
Suffix:
Gender:M
Credentials:DMD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 574
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:IL
Mailing Address - Zip Code:61087-0574
Mailing Address - Country:US
Mailing Address - Phone:815-745-2038
Mailing Address - Fax:815-745-2038
Practice Address - Street 1:104 CATLIN ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:IL
Practice Address - Zip Code:61087-7704
Practice Address - Country:US
Practice Address - Phone:815-745-2038
Practice Address - Fax:815-745-2038
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist