Healthcare Provider Details

I. General information

NPI: 1477780633
Provider Name (Legal Business Name): MIKE C WURBEL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2556 W NORTH AVE
CHICAGO IL
60647-5216
US

IV. Provider business mailing address

2556 W NORTH AVE
CHICAGO IL
60647-5216
US

V. Phone/Fax

Practice location:
  • Phone: 773-360-1281
  • Fax: 773-360-1285
Mailing address:
  • Phone: 773-360-1281
  • Fax: 773-360-1285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2009014660
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019027166
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: