Provider Demographics
NPI:1477132561
Name:KONIECZKI, COREY DANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:DANE
Last Name:KONIECZKI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 FOXBOROUGH LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-7063
Mailing Address - Country:US
Mailing Address - Phone:815-979-2855
Mailing Address - Fax:
Practice Address - Street 1:2028 E RIVERSIDE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4800
Practice Address - Country:US
Practice Address - Phone:815-315-4073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-06-25
Deactivation Date:2021-05-09
Deactivation Code:
Reactivation Date:2021-06-25
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program