Healthcare Provider Details

I. General information

NPI: 1043825078
Provider Name (Legal Business Name): GREAT SMILE DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2660 WINDMILL PKWY
HENDERSON NV
89074-3385
US

IV. Provider business mailing address

720 OSTERMAN AVE STE 304
DEERFIELD IL
60015-4339
US

V. Phone/Fax

Practice location:
  • Phone: 702-309-0906
  • Fax: 252-150-0387
Mailing address:
  • Phone: 847-945-1050
  • Fax: 847-940-0433

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: JACQUELINE MORALES
Title or Position: DISTRICT MANAGER
Credential:
Phone: 847-945-1050