Healthcare Provider Details

I. General information

NPI: 1417877721
Provider Name (Legal Business Name): VIENTO DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 S BLUE ISLAND AVE
CHICAGO IL
60608-2282
US

IV. Provider business mailing address

1461 S BLUE ISLAND AVE
CHICAGO IL
60608-2282
US

V. Phone/Fax

Practice location:
  • Phone: 734-748-8742
  • Fax:
Mailing address:
  • Phone: 734-748-8742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW ALEX LUPSAN
Title or Position: OWNER/GENERAL DENTIST
Credential: DDS
Phone: 734-748-8742