Provider Demographics
NPI:1629151717
Name:MEHTA, CHANDRAKANT K (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHANDRAKANT
Middle Name:K
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 1:2435 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5461
Mailing Address - Country:US
Mailing Address - Phone:815-725-0260
Mailing Address - Fax:815-725-0260
Practice Address - Street 1:2435 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5461
Practice Address - Country:US
Practice Address - Phone:815-725-0260
Practice Address - Fax:815-725-0260
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005424Medicaid