Provider Demographics
NPI:1821482001
Name:WAGENHEJM-CIESIELSKI, KRYSTYNA
Entity Type:Individual
Prefix:DR
First Name:KRYSTYNA
Middle Name:
Last Name:WAGENHEJM-CIESIELSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 N MILWAUKEE AVE
Mailing Address - Street 2:STE 2-21B
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3159
Mailing Address - Country:US
Mailing Address - Phone:847-581-9400
Mailing Address - Fax:847-581-9044
Practice Address - Street 1:7900 N MILWAUKEE AVE
Practice Address - Street 2:STE 2-21B
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3159
Practice Address - Country:US
Practice Address - Phone:847-581-9400
Practice Address - Fax:847-581-9044
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0244601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice