Provider Demographics
NPI:1649331695
Name:MARITATO, MARIO BENJAMIN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:BENJAMIN
Last Name:MARITATO
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 1:5008 GREEN BAY RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1790
Mailing Address - Country:US
Mailing Address - Phone:262-657-0504
Mailing Address - Fax:262-657-0515
Practice Address - Street 1:5008 GREEN BAY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1790
Practice Address - Country:US
Practice Address - Phone:262-657-0504
Practice Address - Fax:262-657-0515
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice