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General NPI Number Information
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NPI Number | 1023549078
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Entity Type | Organization
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Legal Business Name | MY SMILE INC
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Dates
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Enumeration Date | 03/22/2017
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Last Update Date | 03/22/2017
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Provider Practice Location Address
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Address Line | 1475 E OAKTON ST SUITE 2
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City | DES PLAINES
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State | IL
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Zip | 60018-2166
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Country | US
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Telephone | 224-443-4988
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Fax |
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Provider Business Mailing Address
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Address Line | 6147 LINCOLN AVE UNIT E
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City | MORTON GROVE
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State | IL
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Zip | 60053-2900
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. HIDAYATHULLA KHAN
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Credential | DMD
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Telephone | 224-766-9876
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019030623
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License Number State | IL
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