Provider Demographics
NPI:1619516556
Name:PERALTA, LUIS ALBERTO (DMD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ALBERTO
Last Name:PERALTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 W SUPERIOR ST # 2S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-8528
Mailing Address - Country:US
Mailing Address - Phone:917-742-4608
Mailing Address - Fax:
Practice Address - Street 1:698 E BURRELL DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-9000
Practice Address - Country:US
Practice Address - Phone:219-662-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031829122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist