MEDICARE: TIMELESS SMILES DENTAL

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	019023222	IL

General Provider Information

NPI Number	:	1598161432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMELESS SMILES DENTAL

Provider Business Mailing Address
First Line	:	10412 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2018
Country	:	US
Telephone Number	:	773-233-1900
Fax Number	:	773-233-9967

Provider Business Practice Location Address
First Line	:	10412 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2018
Country	:	US
Telephone Number	:	773-233-1900
Fax Number	:	773-233-9967

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. KELLIE A RHODES-GAYLES
Credential	:	D.D.S.
Telephone Number	:	773-233-1900

Provider Enumeration Date	:	11/04/2014
Last Update Date	:	11/04/2014

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Directions to “TIMELESS SMILES DENTAL ” Practice Location

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