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General NPI Number Information
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NPI Number | 1306379185
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Entity Type | Organization
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Legal Business Name | MINT DENTAL CARE LTD
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Dates
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Enumeration Date | 04/07/2017
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Last Update Date | 04/07/2017
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Provider Practice Location Address
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Address Line | 4635 W 63RD ST STE D
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City | CHICAGO
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State | IL
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Zip | 60629-5559
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Country | US
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Telephone | 872-254-1008
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Fax | 847-665-0416
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Provider Business Mailing Address
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Address Line | 4635 W 63RD ST STE D
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City | CHICAGO
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State | IL
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Zip | 60629-5559
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Country | US
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Telephone | 872-254-1008
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Fax | 847-665-0416
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Authorized Official
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Title or Position | PRESIDENT
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Name | HUI JUN PARK
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Credential |
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Telephone | 872-254-1008
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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 | 019025067
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License Number State | IL
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