Provider Demographics
NPI:1811015084
Name:NORTHWEST ORAL & MAXILLOFACIAL SURGERY INC
Entity Type:Organization
Organization Name:NORTHWEST ORAL & MAXILLOFACIAL SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAUTHIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-392-6220
Mailing Address - Street 1:1600 W CENTRAL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005
Mailing Address - Country:US
Mailing Address - Phone:847-392-6220
Mailing Address - Fax:847-392-6236
Practice Address - Street 1:1600 W CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005
Practice Address - Country:US
Practice Address - Phone:847-392-6220
Practice Address - Fax:847-392-6236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019016047122300000X
IL019019734122300000X
IL019015876122300000X
IL019025795122300000X
IL0210010871223S0112X
IL0210014071223S0112X
IL0210011571223S0112X
IL0210021231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U95172Medicare UPIN
T38270Medicare UPIN
U11349Medicare UPIN
T38369Medicare UPIN