Healthcare Provider Details

I. General information

NPI: 1730636267
Provider Name (Legal Business Name): TARAS MARTYNIOUK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S GREENLEAF ST STE 203
GURNEE IL
60031-5708
US

IV. Provider business mailing address

310 S GREENLEAF ST STE 203
GURNEE IL
60031-5708
US

V. Phone/Fax

Practice location:
  • Phone: 847-623-5915
  • Fax:
Mailing address:
  • Phone: 847-623-5915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.030683
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number108875
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019.030683
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: