Provider Demographics
NPI:1669567491
Name:MINALT, JOHN E (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:MINALT
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 1:200 W FRONT ST STE 90
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-2709
Mailing Address - Country:US
Mailing Address - Phone:815-236-8694
Mailing Address - Fax:
Practice Address - Street 1:200 W FRONT ST STE 90
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-2709
Practice Address - Country:US
Practice Address - Phone:815-236-8694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6204-15122300000X
IL019-0212501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist