Provider Demographics
NPI:1700805512
Name:JANKOWSKI, WALTER J (DMD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:JANKOWSKI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5011 N. ILLINOIS ST.
Mailing Address - Street 2:STE 1
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-1717
Mailing Address - Country:US
Mailing Address - Phone:618-222-1942
Mailing Address - Fax:618-222-2819
Practice Address - Street 1:5011 N. ILLINOIS ST.
Practice Address - Street 2:STE 1
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-1717
Practice Address - Country:US
Practice Address - Phone:618-222-1942
Practice Address - Fax:618-222-2819
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190246601223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1318983OtherUNITED CONCORDIA PROVIDER