Provider Demographics
NPI:1528629656
Name:MATAVOOSI, TENY (DDS)
Entity type:Individual
Prefix:DR
First Name:TENY
Middle Name:
Last Name:MATAVOOSI
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 1:324 S MAPLE AVE APT 3B
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3430
Mailing Address - Country:US
Mailing Address - Phone:818-731-7383
Mailing Address - Fax:
Practice Address - Street 1:7110 W ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2204
Practice Address - Country:US
Practice Address - Phone:773-432-4744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0322271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty