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General NPI Number Information
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NPI Number | 1063079150
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Entity Type | Organization
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Legal Business Name | SMILES OF CARPENTERSVILLE PLLC
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Dates
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Enumeration Date | 05/23/2019
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Last Update Date | 12/03/2024
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Provider Practice Location Address
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Address Line | 27 S WESTERN AVE
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City | CARPENTERSVILLE
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State | IL
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Zip | 60110-1715
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Country | US
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Telephone | 224-805-0502
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Fax | 847-496-5057
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Provider Business Mailing Address
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Address Line | 27 S WESTERN AVE STE E
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City | CARPENTERSVILLE
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State | IL
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Zip | 60110-1715
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Country | US
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Telephone | 224-805-0502
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Fax | 847-783-6552
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SANDHYA GRACE PALLAM
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Credential | DDS
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Telephone | 847-783-6544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number |
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License Number State |
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