Healthcare Provider Details

I. General information

NPI: 1225627532
Provider Name (Legal Business Name): CONOR M WIERUS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10735 S CICERO AVE STE 101
OAK LAWN IL
60453-6210
US

IV. Provider business mailing address

9330 BEN C PRATT/6 MILE CYPRESS PKWY
FORT MYERS FL
33966-6505
US

V. Phone/Fax

Practice location:
  • Phone: 708-942-7287
  • Fax:
Mailing address:
  • Phone: 239-337-1008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.032978
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN25773
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: