Provider Demographics
NPI:1457975971
Name:VASTLIK, BRENDAN THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENDAN
Middle Name:THOMAS
Last Name:VASTLIK
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 1:23820 W DAYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-7711
Mailing Address - Country:US
Mailing Address - Phone:815-992-8393
Mailing Address - Fax:
Practice Address - Street 1:46 S WEBER RD
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-4947
Practice Address - Country:US
Practice Address - Phone:815-293-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019032600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist