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General NPI Number Information
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NPI Number | 1013464593
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Entity Type | Organization
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Legal Business Name | ISMILE DENTAL
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Dates
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Enumeration Date | 09/01/2016
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Last Update Date | 09/01/2016
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Provider Practice Location Address
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Address Line | 4953 WEST FULLERTON AVE
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City | CHICAGO
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State | IL
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Zip | 60639
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Country | US
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Telephone | 773-887-3244
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Fax | 773-897-6697
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Provider Business Mailing Address
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Address Line | 4953 W FULLERTON AVE
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City | CHICAGO
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State | IL
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Zip | 60639-2505
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Country | US
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Telephone | 773-655-7455
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Fax | 773-897-6697
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | YESENIA DELGADO
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Credential |
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Telephone | 773-887-3244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019-027782
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License Number State | IL
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