Provider Demographics
NPI:1891814695
Name:MEKAELIAN, ALTA E (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALTA
Middle Name:E
Last Name:MEKAELIAN
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 1:135 NORTH ROUTE MILWAUKEE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031
Mailing Address - Country:US
Mailing Address - Phone:847-623-2340
Mailing Address - Fax:847-623-2384
Practice Address - Street 1:135 N IL ROUTE 21
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3808
Practice Address - Country:US
Practice Address - Phone:847-623-2340
Practice Address - Fax:847-623-2384
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL201401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice