Provider Demographics
NPI:1912458399
Name:DZIARSKI, MATTHEW C (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:C
Last Name:DZIARSKI
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 1:5640 CLAYTON CIR
Mailing Address - Street 2:PO BOX 967
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9503
Mailing Address - Country:US
Mailing Address - Phone:815-623-7366
Mailing Address - Fax:815-623-7331
Practice Address - Street 1:5640 CLAYTON CIR
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9503
Practice Address - Country:US
Practice Address - Phone:815-623-7366
Practice Address - Fax:815-623-7331
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030880122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist