Healthcare Provider Details

I. General information

NPI: 1750754792
Provider Name (Legal Business Name): SMILE CENTRAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7131 N RIDGE BLVD
CHICAGO IL
60645-3616
US

IV. Provider business mailing address

7131 N RIDGE BLVD
CHICAGO IL
60645-3616
US

V. Phone/Fax

Practice location:
  • Phone: 773-764-7575
  • Fax: 773-764-2951
Mailing address:
  • Phone: 773-764-7575
  • Fax: 773-764-2951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019022787
License Number StateIL

VIII. Authorized Official

Name: DR. GREGORY CHIPP
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 773-764-7575