Provider Demographics
NPI:1992824957
Name:WIELGOS, ALAN RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:RICHARD
Last Name:WIELGOS
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 1:9844 33RD CT
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-5701
Mailing Address - Country:US
Mailing Address - Phone:262-695-2605
Mailing Address - Fax:847-872-2579
Practice Address - Street 1:2671 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-2628
Practice Address - Country:US
Practice Address - Phone:847-872-4782
Practice Address - Fax:847-872-2579
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist