Provider Demographics
NPI:1184823569
Name:JOHNSBURG DENTAL CENTER
Entity Type:Organization
Organization Name:JOHNSBURG DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CONRAD
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:MAZESKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-344-0028
Mailing Address - Street 1:4113 JOHNSBURG ROAD
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60050-2123
Mailing Address - Country:US
Mailing Address - Phone:815-344-0028
Mailing Address - Fax:815-344-2466
Practice Address - Street 1:4113 JOHNSBURG ROAD
Practice Address - Street 2:
Practice Address - City:JOHNSBURG
Practice Address - State:IL
Practice Address - Zip Code:60050-2123
Practice Address - Country:US
Practice Address - Phone:815-344-0028
Practice Address - Fax:815-344-2466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X, 1223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty