Healthcare Provider Details

I. General information

NPI: 1275443566
Provider Name (Legal Business Name): ALTA ARCHER HEIGHTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4889 S ARCHER AVE
CHICAGO IL
60632-3621
US

IV. Provider business mailing address

555 W KINZIE ST APT 1007E
CHICAGO IL
60654-5842
US

V. Phone/Fax

Practice location:
  • Phone: 773-295-7600
  • Fax:
Mailing address:
  • Phone: 218-329-2753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: CHRIS WORTH
Title or Position: OWNER / PARTNER
Credential: DDS
Phone: 218-329-2753