Healthcare Provider Details

I. General information

NPI: 1235675919
Provider Name (Legal Business Name): LUCKY SMILE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 HUNTINGTON LN
WHEELING IL
60090-6908
US

IV. Provider business mailing address

367 SATINWOOD TER
BUFFALO GROVE IL
60089-4605
US

V. Phone/Fax

Practice location:
  • Phone: 847-229-1700
  • Fax: 847-947-8705
Mailing address:
  • Phone: 484-241-1888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019029466
License Number StateIL

VIII. Authorized Official

Name: LAKSHMI UPPALA
Title or Position: OWNER
Credential: DDS
Phone: 484-241-1888