Provider Demographics
NPI:1912070228
Name:ILLIANA ENDODONTICS, P.C.
Entity Type:Organization
Organization Name:ILLIANA ENDODONTICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-755-2021
Mailing Address - Street 1:500 ASHLAND AVE.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411
Mailing Address - Country:US
Mailing Address - Phone:708-755-2021
Mailing Address - Fax:708-755-2027
Practice Address - Street 1:500 ASHLAND AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411
Practice Address - Country:US
Practice Address - Phone:708-755-2021
Practice Address - Fax:708-755-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty