Provider Demographics
NPI:1841626793
Name:DR. JAY A WYGODNY DMD, PC
Entity type:Organization
Organization Name:DR. JAY A WYGODNY DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WYGODNY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-265-4420
Mailing Address - Street 1:2592 E GRAND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5915
Mailing Address - Country:US
Mailing Address - Phone:847-265-4420
Mailing Address - Fax:847-265-4429
Practice Address - Street 1:2592 E GRAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-5915
Practice Address - Country:US
Practice Address - Phone:847-265-4420
Practice Address - Fax:847-265-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019212261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental