Provider Demographics
NPI:1487727491
Name:SODERSTROM, JAMES WALTER (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WALTER
Last Name:SODERSTROM
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 1:2121 W GALENA BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3274
Mailing Address - Country:US
Mailing Address - Phone:630-897-7839
Mailing Address - Fax:
Practice Address - Street 1:2121 W GALENA BLVD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3274
Practice Address - Country:US
Practice Address - Phone:630-897-7839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2019-10-23
Deactivation Date:2019-10-02
Deactivation Code:
Reactivation Date:2019-10-23
Provider Licenses
StateLicense IDTaxonomies
IL019.0144081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice