Provider Demographics
NPI:1083477269
Name:MITHAIWALA, HATIMALI IMTIAZ HUSAIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:HATIMALI
Middle Name:IMTIAZ HUSAIN
Last Name:MITHAIWALA
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 1:1010 W US ROUTE 6
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-8942
Mailing Address - Country:US
Mailing Address - Phone:815-942-0010
Mailing Address - Fax:
Practice Address - Street 1:1010 W US ROUTE 6
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-8942
Practice Address - Country:US
Practice Address - Phone:815-942-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034773122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist