Provider Demographics
NPI:1891827499
Name:MEHTA, ASHISH (DMD)
Entity Type:Individual
Prefix:DR
First Name:ASHISH
Middle Name:
Last Name:MEHTA
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 1:2965 S MACARTHUR BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5018
Mailing Address - Country:US
Mailing Address - Phone:217-793-6909
Mailing Address - Fax:217-793-6995
Practice Address - Street 1:2965 S MACARTHUR BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-5018
Practice Address - Country:US
Practice Address - Phone:217-793-6909
Practice Address - Fax:217-793-6995
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
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
IL9181509Medicaid