Provider Demographics
NPI:1235787730
Name:ALTA DENTAL LLC
Entity Type:Organization
Organization Name:ALTA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-329-2753
Mailing Address - Street 1:565 W QUINCY ST UNIT 1506
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-2911
Mailing Address - Country:US
Mailing Address - Phone:218-329-2753
Mailing Address - Fax:
Practice Address - Street 1:5892 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-1658
Practice Address - Country:US
Practice Address - Phone:218-329-2753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental