Provider Demographics
NPI:1609084482
Name:JAGODZINSKI, WALTER JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:JOHN
Last Name:JAGODZINSKI
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 1:903 W WHITEGATE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3062
Mailing Address - Country:US
Mailing Address - Phone:773-631-5200
Mailing Address - Fax:773-631-5755
Practice Address - Street 1:6426 N NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1450
Practice Address - Country:US
Practice Address - Phone:773-631-5200
Practice Address - Fax:773-631-5755
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A14077122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist