Provider Demographics
NPI:1992875801
Name:WIRTZ, ROBERT J (DDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WIRTZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15601 CICERO AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-3635
Mailing Address - Country:US
Mailing Address - Phone:708-687-6600
Mailing Address - Fax:708-687-6639
Practice Address - Street 1:15601 CICERO AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-3635
Practice Address - Country:US
Practice Address - Phone:708-687-6600
Practice Address - Fax:708-687-6639
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics