Provider Demographics
NPI:1467893495
Name:MEHTA, PRIYANKA KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:PRIYANKA
Middle Name:KEITH
Last Name:MEHTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2167 WILDWOOD CT
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-6770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 N ROOT ST
Practice Address - Street 2:SUITE #105
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-3429
Practice Address - Country:US
Practice Address - Phone:630-800-1137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.029611122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist