Healthcare Provider Details

I. General information

NPI: 1205902194
Provider Name (Legal Business Name): KEITH MELLOVITZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1893 SHERIDAN RD SUITE 318
HIGHLAND PARK IL
60035
US

IV. Provider business mailing address

1893 SHERIDAN ROAD SUITE 318
HIGHLAND PARK IL
60035
US

V. Phone/Fax

Practice location:
  • Phone: 847-433-9350
  • Fax: 847-433-9355
Mailing address:
  • Phone: 847-433-9350
  • Fax: 847-433-9355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberA17241
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.017241
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: