Healthcare Provider Details

I. General information

NPI: 1790286169
Provider Name (Legal Business Name): ORTHO2SMILE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4326 PRINCE ST
DOWNERS GROVE IL
60515-2875
US

IV. Provider business mailing address

4326 PRINCE ST
DOWNERS GROVE IL
60515-2875
US

V. Phone/Fax

Practice location:
  • Phone: 630-964-0115
  • Fax:
Mailing address:
  • Phone: 630-964-0115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CORINA RADU
Title or Position: OWNER DOCTOR
Credential: DMD
Phone: 630-964-0115