Healthcare Provider Details

I. General information

NPI: 1023526852
Provider Name (Legal Business Name): ALL PERFECT SMILES OF BEVERLY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10601 S WESTERN AVE
CHICAGO IL
60643-3100
US

IV. Provider business mailing address

10601 S WESTERN AVE
CHICAGO IL
60643-3100
US

V. Phone/Fax

Practice location:
  • Phone: 773-238-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: OSCAR G GONZALEZ
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 219-465-8627