Provider Demographics
NPI:1114022191
Name:JUAN G MESA, DDS PC
Entity Type:Organization
Organization Name:JUAN G MESA, DDS PC
Other - Org Name:NONE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:MESA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-267-9777
Mailing Address - Street 1:3190 N ELSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5845
Mailing Address - Country:US
Mailing Address - Phone:773-267-9777
Mailing Address - Fax:773-267-9662
Practice Address - Street 1:3190 N ELSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5845
Practice Address - Country:US
Practice Address - Phone:773-267-9777
Practice Address - Fax:773-267-9662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty