Provider Demographics
NPI:1124039011
Name:WEGRZYN, KEVIN G (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:WEGRZYN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 W CRYSTAL LAKE RD
Mailing Address - Street 2:PO BOX 1690
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-5412
Mailing Address - Country:US
Mailing Address - Phone:815-385-4411
Mailing Address - Fax:815-385-4485
Practice Address - Street 1:4811 W CRYSTAL LAKE RD
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-5412
Practice Address - Country:US
Practice Address - Phone:815-385-4411
Practice Address - Fax:815-385-4485
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice