Provider Demographics
NPI:1245254309
Name:WIDEN, RONALD ROGER (DDS)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:ROGER
Last Name:WIDEN
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 1:2001 N HALSTED ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4365
Mailing Address - Country:US
Mailing Address - Phone:312-266-0044
Mailing Address - Fax:312-266-8772
Practice Address - Street 1:2001 N HALSTED ST
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4365
Practice Address - Country:US
Practice Address - Phone:312-266-0044
Practice Address - Fax:312-266-8772
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice