Provider Demographics
NPI:1760572861
Name:PROSNIEWSKI, MARK JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:PROSNIEWSKI
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 1:116 W BARTLETT AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-4282
Mailing Address - Country:US
Mailing Address - Phone:630-837-2779
Mailing Address - Fax:630-837-2708
Practice Address - Street 1:116 W BARTLETT AVE
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4282
Practice Address - Country:US
Practice Address - Phone:630-837-2779
Practice Address - Fax:630-837-2708
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190183321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL773420Medicare ID - Type UnspecifiedMEDICARE