Healthcare Provider Details

I. General information

NPI: 1790763860
Provider Name (Legal Business Name): BRIAN WARDELL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 CHESTNUT ST SUITE GA
HINSDALE IL
60521-3171
US

IV. Provider business mailing address

522 CHESTNUT ST SUITE GA
HINSDALE IL
60521-3171
US

V. Phone/Fax

Practice location:
  • Phone: 630-655-3636
  • Fax:
Mailing address:
  • Phone: 630-655-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019025869
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number021002266
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: