Provider Demographics
NPI:1255644274
Name:MEHTA, NISHA (DDS)
Entity type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:MEHTA
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 1:777 N MICHIGAN AVE APT 3809
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-6646
Mailing Address - Country:US
Mailing Address - Phone:574-707-3359
Mailing Address - Fax:
Practice Address - Street 1:1649 W CORTLAND ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-8974
Practice Address - Country:US
Practice Address - Phone:574-707-3359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028352122300000X
IL0210025991223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist