Healthcare Provider Details

I. General information

NPI: 1083885271
Provider Name (Legal Business Name): PERFECT SMILE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 W MONTROSE AVE
CHICAGO IL
60613-1214
US

IV. Provider business mailing address

1624 W MONTROSE AVE
CHICAGO IL
60613-1214
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-5600
  • Fax: 773-275-5868
Mailing address:
  • Phone: 773-275-5600
  • Fax: 773-275-5868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026329
License Number StateIL

VIII. Authorized Official

Name: DR. SALMAN UMAR POOTHAWALA
Title or Position: DENTIST
Credential: DDS
Phone: 773-275-5600