Healthcare Provider Details

I. General information

NPI: 1134251523
Provider Name (Legal Business Name): ROGER T WETZEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 PINE AVE
RANTOUL IL
61866-2019
US

IV. Provider business mailing address

3007 WEEPING CHERRY DR
CHAMPAIGN IL
61822-6880
US

V. Phone/Fax

Practice location:
  • Phone: 217-892-2176
  • Fax:
Mailing address:
  • Phone: 217-356-8925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: