Healthcare Provider Details

I. General information

NPI: 1457673410
Provider Name (Legal Business Name): A.E. ATTA, DDS MSD, MD LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LAKE-COOK RD.
DEERFIELD IL
60015
US

IV. Provider business mailing address

1901 SURREY LANE
LAKE FOREST IL
60045
US

V. Phone/Fax

Practice location:
  • Phone: 847-945-2290
  • Fax: 847-945-2380
Mailing address:
  • Phone: 847-945-2290
  • Fax: 847-945-2380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.014011
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number012.000694
License Number StateIL

VIII. Authorized Official

Name: DR. AL E ATTA
Title or Position: CEO
Credential: DDS, MSD, MBA
Phone: 847-295-2855