Healthcare Provider Details

I. General information

NPI: 1073557732
Provider Name (Legal Business Name): MICHAEL LEONARD SIWEK D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8368 GRAND AVE
RIVER GROVE IL
60171-1435
US

IV. Provider business mailing address

8 S 153 MADISON ST.
BURR RIDGE IL
60527-5553
US

V. Phone/Fax

Practice location:
  • Phone: 708-453-0500
  • Fax: 708-453-0580
Mailing address:
  • Phone: 630-321-1055
  • Fax: 708-453-0580

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: