Healthcare Provider Details

I. General information

NPI: 1871696922
Provider Name (Legal Business Name): WILLIAM GUSTAV FLICK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6305 W 95TH ST SUITE 301
OAK LAWN IL
60453-2255
US

IV. Provider business mailing address

6305 W 95TH ST SUITE 301
OAK LAWN IL
60453-2255
US

V. Phone/Fax

Practice location:
  • Phone: 708-425-4300
  • Fax: 708-425-4310
Mailing address:
  • Phone: 708-425-4300
  • Fax: 708-425-4310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019.014839
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number137000009
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number137000009
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number021001050
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: