Healthcare Provider Details

I. General information

NPI: 1023748183
Provider Name (Legal Business Name): HOLDEN DANIELEWICZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 FLORSHEIM DR STE 12
LIBERTYVILLE IL
60048-3712
US

IV. Provider business mailing address

740 FLORSHEIM DR STE 12
LIBERTYVILLE IL
60048-3712
US

V. Phone/Fax

Practice location:
  • Phone: 847-350-7718
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6001000-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019033747
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: