Healthcare Provider Details

I. General information

NPI: 1700805512
Provider Name (Legal Business Name): WALTER J JANKOWSKI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5011 N. ILLINOIS ST. STE 1
FAIRVIEW HEIGHTS IL
62208-1717
US

IV. Provider business mailing address

5011 N. ILLINOIS ST. STE 1
FAIRVIEW HEIGHTS IL
62208-1717
US

V. Phone/Fax

Practice location:
  • Phone: 618-222-1942
  • Fax: 618-222-2819
Mailing address:
  • Phone: 618-222-1942
  • Fax: 618-222-2819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019024660
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019024660
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: