Healthcare Provider Details

I. General information

NPI: 1619516556
Provider Name (Legal Business Name): LUIS ALBERTO PERALTA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1879 N MILWAUKEE AVE STE 1
CHICAGO IL
60647-5689
US

IV. Provider business mailing address

1879 N MILWAUKEE AVE STE 1
CHICAGO IL
60647-5689
US

V. Phone/Fax

Practice location:
  • Phone: 312-429-6506
  • Fax:
Mailing address:
  • Phone: 312-429-6506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.031829
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: