Healthcare Provider Details

I. General information

NPI: 1659665859
Provider Name (Legal Business Name): STEPHEN M WEEKS D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST ROOM 302L
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

801 S PAULINA ST ROOM 302L
CHICAGO IL
60612-7210
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-1661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number019022015
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: