Healthcare Provider Details

I. General information

NPI: 1427665488
Provider Name (Legal Business Name): OLEKSII GUDYM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 W MASON ST
GREEN BAY WI
54303-4707
US

IV. Provider business mailing address

2050 E ALGONQUIN RD STE 610
SCHAUMBURG IL
60173-4166
US

V. Phone/Fax

Practice location:
  • Phone: 888-988-4066
  • Fax:
Mailing address:
  • Phone: 888-988-4066
  • Fax: 847-496-4850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1002444
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: