Healthcare Provider Details

I. General information

NPI: 1447816616
Provider Name (Legal Business Name): SOUTHWEST SMILING DENTAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11141 S KEDZIE AVE
CHICAGO IL
60655-2329
US

IV. Provider business mailing address

836 S MILLER ST
CHICAGO IL
60607-4207
US

V. Phone/Fax

Practice location:
  • Phone: 773-779-1606
  • Fax:
Mailing address:
  • Phone: 773-941-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: JIANJUN HAO
Title or Position: OWNER
Credential:
Phone: 773-941-1010