Healthcare Provider Details

I. General information

NPI: 1912070228
Provider Name (Legal Business Name): ILLIANA ENDODONTICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 RICHARD RD
DYER IN
46311-1936
US

IV. Provider business mailing address

934 RICHARD RD
DYER IN
46311-1936
US

V. Phone/Fax

Practice location:
  • Phone: 219-865-9790
  • Fax: 708-755-2027
Mailing address:
  • Phone: 219-865-9790
  • Fax: 708-755-2027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number021001405
License Number StateIL

VIII. Authorized Official

Name: DR. MICHAEL JOHN MINTZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 708-755-2021