Provider Demographics
NPI:1215142344
Name:MINTZ, MICHAEL ROYAL
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROYAL
Last Name:MINTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:ROYAL
Other - Last Name:MINTZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:990 W FULLERTON AVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2458
Mailing Address - Country:US
Mailing Address - Phone:773-935-1855
Mailing Address - Fax:773-935-1888
Practice Address - Street 1:990 W FULLERTON AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2458
Practice Address - Country:US
Practice Address - Phone:773-935-1855
Practice Address - Fax:773-935-1888
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice