Provider Demographics
NPI:1366724502
Name:STOSICH, MICHAEL S (DMD,MS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:STOSICH
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1275 E BELVIDERE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2082
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1275 E BELVIDERE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2082
Practice Address - Country:US
Practice Address - Phone:847-548-4200
Practice Address - Fax:847-548-4527
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0285581223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics