Provider Demographics
NPI:1548565419
Name:MATUSIEWICZ POPOVICH, THERESA (RDH)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:MATUSIEWICZ POPOVICH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88455 PIKE ROAD
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-4814
Mailing Address - Country:US
Mailing Address - Phone:715-779-3096
Mailing Address - Fax:
Practice Address - Street 1:88455 PIKE RD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814-4814
Practice Address - Country:US
Practice Address - Phone:715-779-3096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6918-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist