Healthcare Provider Details

I. General information

NPI: 1316342041
Provider Name (Legal Business Name): MUELLER DENTAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 S NATOMA AVE
WORTH IL
60482-1930
US

IV. Provider business mailing address

11104 S NATOMA AVE
WORTH IL
60482-1930
US

V. Phone/Fax

Practice location:
  • Phone: 708-448-0333
  • Fax:
Mailing address:
  • Phone: 708-448-0333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019018192
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number019028943
License Number StateIL

VIII. Authorized Official

Name: DR. FREDERICK W. MUELLER
Title or Position: PRESIDENT
Credential: DDS
Phone: 708-448-0333