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General NPI Number Information
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NPI Number | 1508026659
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Entity Type | Individual
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Provider Name | THOMAS PHILIP WANEZEK DDS
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Gender | Male
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Dates
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Enumeration Date | 06/12/2008
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Last Update Date | 06/12/2008
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Provider Practice Location Address
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Address Line | 3278 MAIN STREET
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City | EAST TROY
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State | WI
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Zip | 53120
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Country | US
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Telephone | 262-642-5881
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 15
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City | EAST TROY
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State | WI
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Zip | 53120-0015
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Country | US
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Telephone | 262-642-5881
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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 | 5613-015
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License Number State | WI
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