Provider Demographics
NPI:1730866344
Name:TYSZKOWSKI, NICOLE (DMD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TYSZKOWSKI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 HICKORY TRAIL
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515
Mailing Address - Country:US
Mailing Address - Phone:773-968-9880
Mailing Address - Fax:
Practice Address - Street 1:3009 E 92ND ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4502
Practice Address - Country:US
Practice Address - Phone:773-295-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034228122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentist