Provider Demographics
NPI:1447383740
Name:MEHTA, SANJAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:
Last Name:MEHTA
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 1:1196 W BOUGHTON RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-6567
Mailing Address - Country:US
Mailing Address - Phone:630-759-9929
Mailing Address - Fax:
Practice Address - Street 1:1196 W BOUGHTON RD
Practice Address - Street 2:SUITE J
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-6567
Practice Address - Country:US
Practice Address - Phone:630-759-9929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist