Healthcare Provider Details

I. General information

NPI: 1275227308
Provider Name (Legal Business Name): SMILE HAVEN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 W FULLERTON AVE
CHICAGO IL
60647-2243
US

IV. Provider business mailing address

3939 W FULLERTON AVE
CHICAGO IL
60647-2243
US

V. Phone/Fax

Practice location:
  • Phone: 773-235-0000
  • Fax:
Mailing address:
  • Phone: 773-235-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. AHMED MASSAD
Title or Position: MEMBER
Credential: DMD
Phone: 708-916-2406