Provider Demographics
NPI:1437664976
Name:EARL E WOELTJE JR
Entity Type:Organization
Organization Name:EARL E WOELTJE JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:ERNST
Authorized Official - Last Name:WOELTJE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-672-2195
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-0516
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-06
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty