Provider Demographics
NPI:1508366717
Name:WITKOWSKI, MATTHEW MARK (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MARK
Last Name:WITKOWSKI
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 1:2405 RIVER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-6356
Mailing Address - Country:US
Mailing Address - Phone:313-407-6569
Mailing Address - Fax:
Practice Address - Street 1:20 EXECUTIVE CT STE 1
Practice Address - Street 2:
Practice Address - City:SOUTH BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-9543
Practice Address - Country:US
Practice Address - Phone:847-550-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190320881223G0001X
390200000X
IARES-30652390200000X
IL021.0034571223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program