Provider Demographics
NPI:1669149449
Name:DRS. MELLOVITZ & GRUMET DENTAL ASSOCIATES, L.L.C.
Entity type:Organization
Organization Name:DRS. MELLOVITZ & GRUMET DENTAL ASSOCIATES, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COSTANTINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-433-9350
Mailing Address - Street 1:1893 SHERIDAN RD STE 318
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2646
Mailing Address - Country:US
Mailing Address - Phone:847-433-9350
Mailing Address - Fax:
Practice Address - Street 1:1893 SHERIDAN RD STE 318
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2646
Practice Address - Country:US
Practice Address - Phone:847-433-9350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty