Healthcare Provider Details

I. General information

NPI: 1134253107
Provider Name (Legal Business Name): ROGER EDWIN SIENKIEWICZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8021 W 79TH ST
JUSTICE IL
60458-1607
US

IV. Provider business mailing address

8021 W 79TH ST
JUSTICE IL
60458-1607
US

V. Phone/Fax

Practice location:
  • Phone: 708-458-7766
  • Fax:
Mailing address:
  • Phone: 708-458-7766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: