Provider Demographics
NPI:1073920997
Name:HUTNIK, ALEX I
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:
Last Name:HUTNIK
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17748 WESTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8552
Mailing Address - Country:US
Mailing Address - Phone:708-703-1099
Mailing Address - Fax:
Practice Address - Street 1:809 W DETWEILLER DR
Practice Address - Street 2:SUITE 805A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2149
Practice Address - Country:US
Practice Address - Phone:309-692-1320
Practice Address - Fax:309-692-1355
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0299211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019029921Medicaid