Healthcare Provider Details

I. General information

NPI: 1538592654
Provider Name (Legal Business Name): MATTHEW SEENA HAMEDANI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 05/21/2022
Certification Date: 05/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 OAK PARK AVE
BERWYN IL
60402
US

IV. Provider business mailing address

3116 OAK PARK AVE
BERWYN IL
60402-3031
US

V. Phone/Fax

Practice location:
  • Phone: 708-484-9011
  • Fax: 708-484-9061
Mailing address:
  • Phone: 708-484-9011
  • Fax: 708-484-9061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019029609
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number019-029609
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number019029609
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: