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General NPI Number Information
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NPI Number | 1174837025
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Entity Type | Organization
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Legal Business Name | KEITH W JAESCHKE DDS PC
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Dates
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Enumeration Date | 08/03/2010
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Last Update Date | 08/03/2010
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Provider Practice Location Address
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Address Line | 1545 CREEK DR
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City | MORRIS
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State | IL
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Zip | 60450-3004
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Country | US
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Telephone | 815-942-0182
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Fax | 815-942-0966
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Provider Business Mailing Address
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Address Line | 1545 CREEK DR
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City | MORRIS
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State | IL
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Zip | 60450-3004
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Country | US
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Telephone | 815-942-0182
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Fax | 815-942-0966
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Authorized Official
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Title or Position | OWNER
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Name | DR. KEITH W JAESCHKE
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Credential | DDS
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Telephone | 815-942-0182
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.020128
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.016659
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.016384
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License Number State | IL
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