Healthcare Provider Details

I. General information

NPI: 1235096074
Provider Name (Legal Business Name): DIVINE SMILES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 GRAND CANYON PKWY STE 215
HOFFMAN ESTATES IL
60169-1735
US

IV. Provider business mailing address

4609 AMY DR
CRYSTAL LAKE IL
60014-6362
US

V. Phone/Fax

Practice location:
  • Phone: 989-977-1771
  • Fax:
Mailing address:
  • Phone: 989-977-1771
  • 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: DR. VIBHA BABBAR SHANKARA
Title or Position: OWNER
Credential: DMD
Phone: 989-977-1771