Healthcare Provider Details

I. General information

NPI: 1689908535
Provider Name (Legal Business Name): SMD ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S MCLEAN BLVD STE M
ELGIN IL
60123-1023
US

IV. Provider business mailing address

300 S MCLEAN BLVD STE M
ELGIN IL
60123-1023
US

V. Phone/Fax

Practice location:
  • Phone: 847-531-5250
  • Fax: 847-531-5270
Mailing address:
  • Phone: 847-531-5250
  • Fax: 847-531-5270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021001216
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number021001216
License Number StateIL

VIII. Authorized Official

Name: DR. OSMAR RODRIGUEZ
Title or Position: PRESIDENT/DENTIST
Credential: D.D.S.
Phone: 847-531-5250