Provider Demographics
NPI:1225514672
Name:JANET, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:JANET
Suffix:
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 1:10312 S KILDARE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4804
Mailing Address - Country:US
Mailing Address - Phone:708-601-5666
Mailing Address - Fax:
Practice Address - Street 1:5898 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-8714
Practice Address - Country:US
Practice Address - Phone:608-849-4794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001892-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist