Provider Demographics
NPI:1154397057
Name:MATULIS, NORBERT A (DDS)
Entity type:Individual
Prefix:
First Name:NORBERT
Middle Name:A
Last Name:MATULIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9207 WICKER AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373
Mailing Address - Country:US
Mailing Address - Phone:219-365-8696
Mailing Address - Fax:219-365-2121
Practice Address - Street 1:9207 WICKER AVENUE
Practice Address - Street 2:
Practice Address - City:ST JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373
Practice Address - Country:US
Practice Address - Phone:219-365-8696
Practice Address - Fax:219-365-2121
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7043122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist