MEDICARE: DIVINE SMILES, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1235096074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE SMILES, PLLC

Provider Business Mailing Address
First Line	:	4609 AMY DR
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-6362
Country	:	US
Telephone Number	:	989-977-1771
Fax Number	:

Provider Business Practice Location Address
First Line	:	990 GRAND CANYON PKWY STE 215
Second Line	:
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-1735
Country	:	US
Telephone Number	:	989-977-1771
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. VIBHA BABBAR SHANKARA
Credential	:	DMD
Telephone Number	:	989-977-1771

Provider Enumeration Date	:	01/05/2026
Last Update Date	:	01/05/2026

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Directions to “DIVINE SMILES, PLLC ” Practice Location

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