Provider Demographics
NPI:1841581436
Name:STEPHEN T JAGIELO DDS PC
Entity Type:Organization
Organization Name:STEPHEN T JAGIELO DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:JAGIELO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-969-4441
Mailing Address - Street 1:4913 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-3612
Mailing Address - Country:US
Mailing Address - Phone:630-969-4441
Mailing Address - Fax:630-969-4480
Practice Address - Street 1:4913 MAIN ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-3612
Practice Address - Country:US
Practice Address - Phone:630-969-4441
Practice Address - Fax:630-969-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0015231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty