Provider Demographics
NPI:1235628454
Name:MYNT DENTAL RACINE LLC
Entity Type:Organization
Organization Name:MYNT DENTAL RACINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SASAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLAVI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-381-8281
Mailing Address - Street 1:2731 MANNHEIM RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131-2219
Mailing Address - Country:US
Mailing Address - Phone:630-381-8281
Mailing Address - Fax:
Practice Address - Street 1:6100 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4000
Practice Address - Country:US
Practice Address - Phone:262-999-9998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-03
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty