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General NPI Number Information
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NPI Number | 1821491937
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Entity Type | Organization
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Legal Business Name | WEST SUBURBAN ENDODONTICS LLC
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Dates
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Enumeration Date | 10/02/2014
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Last Update Date | 10/30/2020
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Provider Practice Location Address
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Address Line | 1749 S NAPERVILLE ROAD SUITE 100
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City | WHEATON
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State | IL
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Zip | 60189
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Country | US
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Telephone | 630-653-3636
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Fax | 630-653-3663
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Provider Business Mailing Address
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Address Line | 1749 S NAPERVILLE ROAD SUITE 100
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City | WHEATON
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State | IL
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Zip | 60189
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Country | US
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Telephone | 630-653-3636
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Fax | 630-653-3663
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Authorized Official
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Title or Position | MANAGER
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Name | DR. BRIAN WARDELL
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Credential | DMD
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Telephone | 630-655-3636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 021002266
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License Number State | IL
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