Provider Demographics
NPI:1043384076
Name:DISTEL, JOHN W (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:DISTEL
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-6833
Mailing Address - Country:US
Mailing Address - Phone:847-842-8866
Mailing Address - Fax:847-842-7501
Practice Address - Street 1:321 W NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-6833
Practice Address - Country:US
Practice Address - Phone:847-842-8866
Practice Address - Fax:847-842-7501
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics