Healthcare Provider Details

I. General information

NPI: 1720906704
Provider Name (Legal Business Name): CARL ALLEN WACKER II DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 THORNHILL DR STE A
CAROL STREAM IL
60188-2780
US

IV. Provider business mailing address

4320 ESQUIRE CIR
NAPERVILLE IL
60564-6159
US

V. Phone/Fax

Practice location:
  • Phone: 630-653-0020
  • Fax:
Mailing address:
  • Phone: 248-736-9924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019037298
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: