MEDICARE: WALTER J JANKOWSKI DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019024660	IL
2	122300000X	Dentist	019024660	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1318983	OTHER	IL	UNITED CONCORDIA PROVIDER

General Provider Information

NPI Number	:	1700805512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER J JANKOWSKI DMD

Provider Business Mailing Address
First Line	:	5011 N. ILLINOIS ST.
Second Line	:	STE 1
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-1717
Country	:	US
Telephone Number	:	618-222-1942
Fax Number	:	618-222-2819

Provider Business Practice Location Address
First Line	:	5011 N. ILLINOIS ST.
Second Line	:	STE 1
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-1717
Country	:	US
Telephone Number	:	618-222-1942
Fax Number	:	618-222-2819

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	08/06/2009

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