Provider Demographics
NPI:1598862195
Name:STASIULIS, MARK LEON (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEON
Last Name:STASIULIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106-2455
Mailing Address - Country:US
Mailing Address - Phone:630-860-9080
Mailing Address - Fax:630-860-9086
Practice Address - Street 1:17 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-2455
Practice Address - Country:US
Practice Address - Phone:630-860-9080
Practice Address - Fax:630-860-9086
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice