Healthcare Provider Details

I. General information

NPI: 1063223592
Provider Name (Legal Business Name): FULL SMILE CHICAGO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7441 SOUTHWEST HWY
WORTH IL
60482-1005
US

IV. Provider business mailing address

7441 SOUTHWEST HWY
WORTH IL
60482-1005
US

V. Phone/Fax

Practice location:
  • Phone: 708-448-0468
  • Fax:
Mailing address:
  • Phone: 708-448-0468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER WILLIAMS
Title or Position: CREDENTIALING
Credential:
Phone: 806-353-1055