Healthcare Provider Details

I. General information

NPI: 1669567491
Provider Name (Legal Business Name): JOHN E MINALT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W FRONT ST STE 90
HARVARD IL
60033-2709
US

IV. Provider business mailing address

200 W FRONT ST STE 90
HARVARD IL
60033-2709
US

V. Phone/Fax

Practice location:
  • Phone: 815-236-8694
  • Fax:
Mailing address:
  • Phone: 815-236-8694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6204-15
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-021250
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: