Provider Demographics
NPI:1235347279
Name:WOELTJE, EARL ERNST JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:ERNST
Last Name:WOELTJE
Suffix:JR
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 1:712 N BLOOMINGTON ST
Mailing Address - Street 2:P.O. 516
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2087
Mailing Address - Country:US
Mailing Address - Phone:815-672-2195
Mailing Address - Fax:
Practice Address - Street 1:712 N BLOOMINGTON ST
Practice Address - Street 2:P.O. 516
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2087
Practice Address - Country:US
Practice Address - Phone:815-672-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist