Provider Demographics
NPI:1457673410
Name:A.E. ATTA, DDS MSD, MD LTD.
Entity Type:Organization
Organization Name:A.E. ATTA, DDS MSD, MD LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AL
Authorized Official - Middle Name:E
Authorized Official - Last Name:ATTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD, MBA
Authorized Official - Phone:847-295-2855
Mailing Address - Street 1:1901 SURREY LANE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045
Mailing Address - Country:US
Mailing Address - Phone:847-945-2290
Mailing Address - Fax:847-945-2380
Practice Address - Street 1:400 LAKE-COOK RD.
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015
Practice Address - Country:US
Practice Address - Phone:847-945-2290
Practice Address - Fax:847-945-2380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A.E. ATTA, DDS MSD, MBA LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.014011122300000X
IL012.0006941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty