Provider Demographics
NPI:1205902194
Name:MELLOVITZ, KEITH (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:MELLOVITZ
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 1:1893 SHERIDAN ROAD
Mailing Address - Street 2:SUITE 318
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035
Mailing Address - Country:US
Mailing Address - Phone:847-433-9350
Mailing Address - Fax:847-433-9355
Practice Address - Street 1:1893 SHERIDAN RD
Practice Address - Street 2:SUITE 318
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035
Practice Address - Country:US
Practice Address - Phone:847-433-9350
Practice Address - Fax:847-433-9355
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0172411223G0001X
ILA17241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice