Healthcare Provider Details

I. General information

NPI: 1417104985
Provider Name (Legal Business Name): AMBER J WISHNEVSKI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14955 S VAN DYKE RD
PLAINFIELD IL
60544-5804
US

IV. Provider business mailing address

1935 W HIGHLAND CT
ROMEOVILLE IL
60446-5324
US

V. Phone/Fax

Practice location:
  • Phone: 815-436-4900
  • Fax:
Mailing address:
  • Phone: 815-353-0786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019027667
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: