Provider Demographics
NPI:1447326004
Name:WITKIEWICZ, STANLEY JEROME (DDS)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:JEROME
Last Name:WITKIEWICZ
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 1:715 N MAIN
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002
Mailing Address - Country:US
Mailing Address - Phone:847-395-0894
Mailing Address - Fax:
Practice Address - Street 1:715 N MAIN
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002
Practice Address - Country:US
Practice Address - Phone:847-395-0894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist