Provider Demographics
NPI:1801079090
Name:MAZESKI, CONRAD WALTER (DDS)
Entity type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:WALTER
Last Name:MAZESKI
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 1:4113 JOHNSBURG ROAD
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60050-2123
Mailing Address - Country:US
Mailing Address - Phone:815-344-0028
Mailing Address - Fax:815-344-2466
Practice Address - Street 1:4113 JOHNSBURG ROAD
Practice Address - Street 2:
Practice Address - City:JOHNSBURG
Practice Address - State:IL
Practice Address - Zip Code:60050-2123
Practice Address - Country:US
Practice Address - Phone:815-344-0028
Practice Address - Fax:815-344-2466
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice