=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801090238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK J. NIEKRASZ D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1635 N BALDWIN RD
-----------------------------------------------------
City | PALATINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60074-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-359-8886
-----------------------------------------------------
Fax | 847-963-2331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1635 N BALDWIN RD
-----------------------------------------------------
City | PALATINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60074-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-359-8886
-----------------------------------------------------
Fax | 847-963-2331
-----------------------------------------------------
=====================================================
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 | 19-14121
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------