Healthcare Provider Details

I. General information

NPI: 1841361409
Provider Name (Legal Business Name): UDITT MUKHERJEE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12720 S ROUTE 59 UNIT 102
PLAINFIELD IL
60585-5528
US

IV. Provider business mailing address

12720 S ROUTE 59 UNIT 102
PLAINFIELD IL
60585-5528
US

V. Phone/Fax

Practice location:
  • Phone: 815-254-5480
  • Fax: 216-584-1089
Mailing address:
  • Phone: 815-254-5840
  • Fax: 216-593-7533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-024230
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: