Healthcare Provider Details

I. General information

NPI: 1720510258
Provider Name (Legal Business Name): LARITA SMITH RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 S HALSTED ST
CHICAGO IL
60621-1833
US

IV. Provider business mailing address

1619 W OLIVE AVE
CHICAGO IL
60660-4102
US

V. Phone/Fax

Practice location:
  • Phone: 773-651-3629
  • Fax:
Mailing address:
  • Phone: 773-996-8794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020009349
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: