MEDICARE: THE HEART THAT SMILES MOBILE DENTISTS

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	122300000X	Dentist	019028142	IL

General Provider Information

NPI Number	:	1407112980
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE HEART THAT SMILES MOBILE DENTISTS

Provider Business Mailing Address
First Line	:	2060 RIDGE RD
Second Line	:	N, SUITE 3 LOWER LEVEL
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-1780
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2060 RIDGE RD
Second Line	:	N, SUITE 3 LOWER LEVEL
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-1780
Country	:	US
Telephone Number	:	312-391-1913
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. LATOI RAPHAEL THOMAS
Credential	:	D.D.S
Telephone Number	:	312-391-1913

Provider Enumeration Date	:	04/09/2012
Last Update Date	:	04/09/2012

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