Provider Demographics
NPI:1871666917
Name:WAIDZUNAS, PETER JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOSEPH
Last Name:WAIDZUNAS
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 1:501 N. MILWAUKEE AVENUE
Mailing Address - Street 2:#119
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-2767
Mailing Address - Country:US
Mailing Address - Phone:847-336-7300
Mailing Address - Fax:847-336-1347
Practice Address - Street 1:501 N. MILWAUKEE AVENUE
Practice Address - Street 2:#119
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2767
Practice Address - Country:US
Practice Address - Phone:847-336-7300
Practice Address - Fax:847-336-1347
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190159821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice