=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275265860
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAULINA WISNIEWSKA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2022
-----------------------------------------------------
Last Update Date | 06/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 728 W NORTHWEST HWY
-----------------------------------------------------
City | BARRINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60010-2640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-865-4278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7783 BERKSHIRE DR
-----------------------------------------------------
City | HANOVER PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60133-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-213-6649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.033836
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------