Provider Demographics
NPI:1265531636
Name:MATUSAK, ANNMARIE (DDS)
Entity type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:
Last Name:MATUSAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 MACK RD.
Mailing Address - Street 2:ML 6007
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014
Mailing Address - Country:US
Mailing Address - Phone:513-636-6400
Mailing Address - Fax:513-636-6452
Practice Address - Street 1:3050 MACK RD
Practice Address - Street 2:ML 6007
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014
Practice Address - Country:US
Practice Address - Phone:513-636-6400
Practice Address - Fax:513-636-6452
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0203181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry