Provider Demographics
NPI:1689889727
Name:MICHAEL R MINTZ D.D.S.,P.C.
Entity Type:Organization
Organization Name:MICHAEL R MINTZ D.D.S.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROYAL
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-935-1855
Mailing Address - Street 1:990 W FULLERTON AVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2458
Mailing Address - Country:US
Mailing Address - Phone:773-935-1855
Mailing Address - Fax:773-935-1888
Practice Address - Street 1:990 W FULLERTON AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2458
Practice Address - Country:US
Practice Address - Phone:773-935-1855
Practice Address - Fax:773-935-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty