Healthcare Provider Details

I. General information

NPI: 1386746345
Provider Name (Legal Business Name): STANLEY JOSEPH MATUSIK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST MAIN
CARPENTERSVILLE IL
60110-1724
US

IV. Provider business mailing address

36W171 STURGIS CT
WEST DUNDEE IL
60118-9515
US

V. Phone/Fax

Practice location:
  • Phone: 847-428-5040
  • Fax:
Mailing address:
  • Phone: 847-428-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: