Provider Demographics
NPI:1437690104
Name:WOJTYNA DENTAL LLC
Entity Type:Organization
Organization Name:WOJTYNA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAUSHAAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-454-6000
Mailing Address - Street 1:3024 SR-159
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034
Mailing Address - Country:US
Mailing Address - Phone:618-205-6119
Mailing Address - Fax:618-659-1343
Practice Address - Street 1:6600 WEIGHLOCK DRIVE
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:315-454-6000
Practice Address - Fax:866-803-4943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027575122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty