Healthcare Provider Details

I. General information

NPI: 1891100111
Provider Name (Legal Business Name): SONRISA DENTAL PC ON ARCHER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 S ARCHER AVE 2ND FLOOR
CHICAGO IL
60608-6837
US

IV. Provider business mailing address

3450 S ARCHER AVE 2ND FLOOR
CHICAGO IL
60608-6837
US

V. Phone/Fax

Practice location:
  • Phone: 773-376-1200
  • Fax:
Mailing address:
  • Phone: 773-376-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY LUKASZCZYK
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 630-730-3233