MEDICARE: SPARKLING SMILES FAMILY 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1619491610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARKLING SMILES FAMILY DENTAL

Provider Business Mailing Address
First Line	:	2400 CHICAGO RD
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-4160
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 CHICAGO RD
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-4160
Country	:	US
Telephone Number	:	708-755-2400
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT/ OWNER
Name	:	DR. ESAM JUMANI
Credential	:	DDS
Telephone Number	:	708-755-2400

Provider Enumeration Date	:	08/01/2017
Last Update Date	:	08/01/2017

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