Healthcare Provider Details

I. General information

NPI: 1679870067
Provider Name (Legal Business Name): JUSTIN ALLAN WELKE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2011
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

V. Phone/Fax

Practice location:
  • Phone: 886-600-2273
  • Fax:
Mailing address:
  • Phone: 630-886-1780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number019028612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: