Provider Demographics
NPI:1215003678
Name:MELROSE DENTAL CENTER SERVICE P.C
Entity Type:Organization
Organization Name:MELROSE DENTAL CENTER SERVICE P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:J
Authorized Official - Last Name:ALBERTTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-345-6636
Mailing Address - Street 1:1908 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-3728
Mailing Address - Country:US
Mailing Address - Phone:708-345-6636
Mailing Address - Fax:708-345-6671
Practice Address - Street 1:1908 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3728
Practice Address - Country:US
Practice Address - Phone:708-345-6636
Practice Address - Fax:708-345-6671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021046122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty