Healthcare Provider Details

I. General information

NPI: 1568071827
Provider Name (Legal Business Name): GREAT SMILE DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8445 W FLAMINGO RD
LAS VEGAS NV
89147-4166
US

IV. Provider business mailing address

720 OSTERMAN AVE STE 304
DEERFIELD IL
60015-4339
US

V. Phone/Fax

Practice location:
  • Phone: 702-309-0909
  • Fax: 725-228-7025
Mailing address:
  • Phone: 847-945-1050
  • Fax: 847-940-0433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

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