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: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 GRAND AVE
WAUKEGAN IL
60085-2372
US

IV. Provider business mailing address

1461 S BLUE ISLAND AVE
CHICAGO IL
60608-2282
US

V. Phone/Fax

Practice location:
  • Phone: 847-662-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.034201
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: