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General NPI Number Information
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NPI Number | 1144579905
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Entity Type | Organization
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Legal Business Name | MINALT & WOJCICKI DENTAL GROUP LLC
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Dates
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Enumeration Date | 09/07/2012
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Last Update Date | 09/07/2012
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Provider Practice Location Address
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Address Line | 1 TIFFANY PT SUITE 209
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-2936
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Country | US
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Telephone | 630-671-0700
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Fax |
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Provider Business Mailing Address
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Address Line | 1 TIFFANY PT SUITE 209
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-2936
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Country | US
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Telephone | 630-671-0700
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. JOHN MINALT
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Credential | DDS
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Telephone | 630-671-0700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019029179
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019021250
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License Number State | IL
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