Provider Demographics
NPI:1427202779
Name:WELU, JOHN C (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:WELU
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 1:800 S. MILWAUKEE AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048
Mailing Address - Country:US
Mailing Address - Phone:847-362-6660
Mailing Address - Fax:847-362-6703
Practice Address - Street 1:800 S. MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-362-6660
Practice Address - Fax:847-362-6703
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A14437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
19A14437OtherLICENSE NO