Healthcare Provider Details

I. General information

NPI: 1508366717
Provider Name (Legal Business Name): MATTHEW MARK WITKOWSKI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 EXECUTIVE CT STE 1
SOUTH BARRINGTON IL
60010-9543
US

IV. Provider business mailing address

2405 RIVER WOODS DR
NAPERVILLE IL
60565-6356
US

V. Phone/Fax

Practice location:
  • Phone: 847-550-3460
  • Fax:
Mailing address:
  • Phone: 313-407-6569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number021.003457
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019032088
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRES-30652
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: