Provider Demographics
NPI:1376627943
Name:MINALT, EUGENE JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:JOHN
Last Name:MINALT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 N. LINDER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641
Mailing Address - Country:US
Mailing Address - Phone:773-545-0041
Mailing Address - Fax:
Practice Address - Street 1:3400 N. LINDER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641
Practice Address - Country:US
Practice Address - Phone:773-545-0041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4663T1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506582Medicaid