Healthcare Provider Details

I. General information

NPI: 1821491937
Provider Name (Legal Business Name): WEST SUBURBAN ENDODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1749 S NAPERVILLE ROAD SUITE 100
WHEATON IL
60189
US

IV. Provider business mailing address

1749 S NAPERVILLE ROAD SUITE 100
WHEATON IL
60189
US

V. Phone/Fax

Practice location:
  • Phone: 630-653-3636
  • Fax: 630-653-3663
Mailing address:
  • Phone: 630-653-3636
  • Fax: 630-653-3663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number021002266
License Number StateIL

VIII. Authorized Official

Name: DR. BRIAN WARDELL
Title or Position: MANAGER
Credential: DMD
Phone: 630-655-3636