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General NPI Number Information
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NPI Number | 1386374791
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Entity Type | Individual
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Provider Name | DR. CHARLIE MALZENSKI
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Gender | Male
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Dates
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Enumeration Date | 06/16/2022
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Last Update Date | 06/16/2022
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Provider Practice Location Address
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Address Line | 342 RANDALL RD
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City | SOUTH ELGIN
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State | IL
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Zip | 60177-2261
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Country | US
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Telephone | 630-883-8146
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Fax |
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Provider Business Mailing Address
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Address Line | 3000 WHITE OAK LN
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City | OAK BROOK
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State | IL
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Zip | 60523-2500
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Country | US
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Telephone | 630-209-3680
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.033686
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License Number State | IL
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