Provider Demographics
NPI:1902951239
Name:WITEK, RICHARD JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOSEPH
Last Name:WITEK
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 1:3001 A SIXTH STREET
Mailing Address - Street 2:GREAT LAKES NAVAL HEALTH CLINIC 200H
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088
Mailing Address - Country:US
Mailing Address - Phone:847-688-2100
Mailing Address - Fax:
Practice Address - Street 1:2351 CRYSTAL RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-5982
Practice Address - Country:US
Practice Address - Phone:847-498-6931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice