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General NPI Number Information
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NPI Number | 1609084482
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Entity Type | Individual
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Provider Name | WALTER JOHN JAGODZINSKI D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 05/18/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 6426 N NORTHWEST HWY
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City | CHICAGO
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State | IL
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Zip | 60631-1450
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Country | US
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Telephone | 773-631-5200
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Fax | 773-631-5755
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Provider Business Mailing Address
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Address Line | 903 W WHITEGATE DR
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City | MOUNT PROSPECT
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State | IL
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Zip | 60056-3062
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Country | US
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Telephone | 773-631-5200
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Fax | 773-631-5755
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 19A14077
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License Number State | IL
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