Healthcare Provider Details

I. General information

NPI: 1740400878
Provider Name (Legal Business Name): GREGORY JAMES MATKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7124 W DIVERSEY AVE
CHICAGO IL
60707
US

IV. Provider business mailing address

7124 W DIVERSEY AVE
CHICAGO IL
60707
US

V. Phone/Fax

Practice location:
  • Phone: 773-237-8855
  • Fax: 773-237-8838
Mailing address:
  • Phone: 773-237-8855
  • Fax: 773-237-8838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19024311
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: