DERIK P DECONINCK Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

TEMPORARY DENTAL TRAINING LICENSE

License Number

018000867

License Status

NOT RENEWED

Business

First Name

DERIK

Middle

Last Name

DECONINCK

Business Name

DERIK P DECONINCK

Original Issue Date

07/14/1995

Effective Date

07/14/1995

Expiration Date

06/30/1996

City

NORTH CHICAGO

State

Zip

60064

County

LAKE

Specialty/Qualifier

General Practice Residency

Ever Disciplined

LastModifiedDate

10/12/2005