Provider Demographics
NPI:1982793105
Name:KINZLER, WAYNE R (DDS)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:R
Last Name:KINZLER
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 1:2210 DEAN ST
Mailing Address - Street 2:E
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-1066
Mailing Address - Country:US
Mailing Address - Phone:630-377-0034
Mailing Address - Fax:630-377-3877
Practice Address - Street 1:2210 DEAN ST
Practice Address - Street 2:E
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1066
Practice Address - Country:US
Practice Address - Phone:630-377-0034
Practice Address - Fax:630-377-3877
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190148911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19014891OtherLICENSE