Provider Demographics
NPI:1508047879
Name:WEGNER, THOMAS W (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:WEGNER
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 1:1144 LAKE ST STE 213
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1043
Mailing Address - Country:US
Mailing Address - Phone:708-383-0330
Mailing Address - Fax:
Practice Address - Street 1:1144 LAKE ST STE 213
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1043
Practice Address - Country:US
Practice Address - Phone:708-383-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice