Provider Demographics
NPI:1124165915
Name:MATISKO, MICHAEL WILLIAM JR (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:MATISKO
Suffix:JR
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 JAMISON LN
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-2327
Mailing Address - Country:US
Mailing Address - Phone:412-823-8908
Mailing Address - Fax:412-349-0097
Practice Address - Street 1:170 JAMISON LN
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-2327
Practice Address - Country:US
Practice Address - Phone:412-823-8908
Practice Address - Fax:412-349-0097
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-025303-L1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics