Provider Demographics
NPI:1780757955
Name:ANTOLAK, JOSEPH FRANCIS (DDS)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:FRANCIS
Last Name:ANTOLAK
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 1:460 COVENTRY LANE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-356-1200
Mailing Address - Fax:
Practice Address - Street 1:460 COVENTRY LANE
Practice Address - Street 2:SUITE 104
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-356-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice