Provider Demographics
NPI:1013131168
Name:MAKSYMIUK, MICHAEL MATTHEW (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MATTHEW
Last Name:MAKSYMIUK
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 1:12 GODFREY PL
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-3030
Mailing Address - Country:US
Mailing Address - Phone:203-762-9480
Mailing Address - Fax:203-834-1255
Practice Address - Street 1:12 GODFREY PL
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-3030
Practice Address - Country:US
Practice Address - Phone:203-762-9480
Practice Address - Fax:203-834-1255
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0092181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice