Provider Demographics
NPI:1821441312
Name:IWASZCZYSZYN, AGNIESZKA (DMD)
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:
Last Name:IWASZCZYSZYN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 7TH AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2673
Mailing Address - Country:US
Mailing Address - Phone:708-291-0354
Mailing Address - Fax:
Practice Address - Street 1:1015 7TH AVE APT 6
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2673
Practice Address - Country:US
Practice Address - Phone:708-291-0354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist