Provider Demographics
NPI:1174837025
Name:KEITH W JAESCHKE DDS PC
Entity Type:Organization
Organization Name:KEITH W JAESCHKE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:W
Authorized Official - Last Name:JAESCHKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-942-0182
Mailing Address - Street 1:1545 CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-3004
Mailing Address - Country:US
Mailing Address - Phone:815-942-0182
Mailing Address - Fax:815-942-0966
Practice Address - Street 1:1545 CREEK DR
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-3004
Practice Address - Country:US
Practice Address - Phone:815-942-0182
Practice Address - Fax:815-942-0966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.016384122300000X
IL019.020128122300000X
IL019.016659122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty