Provider Demographics
NPI:1831749282
Name:WESTWYN DENTAL LLC
Entity type:Organization
Organization Name:WESTWYN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:CLEMENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-795-1255
Mailing Address - Street 1:6901 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2919
Mailing Address - Country:US
Mailing Address - Phone:708-795-1255
Mailing Address - Fax:
Practice Address - Street 1:6901 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2919
Practice Address - Country:US
Practice Address - Phone:708-795-1255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty