Healthcare Provider Details

I. General information

NPI: 1619692811
Provider Name (Legal Business Name): MATTHEW LUPSAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6560 W FULLERTON AVE UNIT C106 STE T
CHICAGO IL
60707
US

IV. Provider business mailing address

16157 WHITE HAVEN DR
NORTHVILLE MI
48168-2326
US

V. Phone/Fax

Practice location:
  • Phone: 773-385-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.034201
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: