Provider Demographics
NPI:1023139425
Name:JANICZEK, RICHARD M (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:JANICZEK
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 1:10359 RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-1585
Mailing Address - Country:US
Mailing Address - Phone:708-422-1002
Mailing Address - Fax:708-422-1002
Practice Address - Street 1:10359 RIDGELAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1585
Practice Address - Country:US
Practice Address - Phone:708-422-1002
Practice Address - Fax:708-422-1002
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice