Provider Demographics
NPI:1851771703
Name:MONTATSKIY, MAKSIM (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAKSIM
Middle Name:
Last Name:MONTATSKIY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 BRANDYWYN LN
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1105
Mailing Address - Country:US
Mailing Address - Phone:312-375-8622
Mailing Address - Fax:
Practice Address - Street 1:5439 DURAND AVE STE 210
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-5058
Practice Address - Country:US
Practice Address - Phone:262-583-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030546122300000X
IL021.0030111223E0200X
WI1001127-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223E0200XDental ProvidersDentistEndodontics