Provider Demographics
NPI:1164888236
Name:JESSICA MEHTA, D.D.S. P.C.
Entity Type:Organization
Organization Name:JESSICA MEHTA, D.D.S. P.C.
Other - Org Name:CHICAGO LOOP DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-372-3323
Mailing Address - Street 1:25 E WASHINGTON ST STE 1121
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1713
Mailing Address - Country:US
Mailing Address - Phone:312-372-3323
Mailing Address - Fax:312-372-0499
Practice Address - Street 1:25 E WASHINGTON ST STE 1121
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1713
Practice Address - Country:US
Practice Address - Phone:312-372-3323
Practice Address - Fax:312-372-0499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty