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General NPI Number Information
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NPI Number | 1104081884
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Entity Type | Organization
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Legal Business Name | SCHOOL HOUSE DENTAL SERVICE
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Dates
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Enumeration Date | 07/22/2008
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Last Update Date | 07/22/2008
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Provider Practice Location Address
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Address Line | 2000 W 95TH ST
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City | CHICAGO
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State | IL
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Zip | 60643-1116
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Country | US
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Telephone | 773-881-3911
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Fax | 773-881-4058
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Provider Business Mailing Address
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Address Line | 2000 W 95TH ST
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City | CHICAGO
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State | IL
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Zip | 60643-1116
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Country | US
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Telephone | 773-881-3911
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Fax | 773-881-4058
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JERROLD W. SMITH
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Credential | D.D.S.
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Telephone | 773-881-3911
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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 | 019016584
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License Number State | IL
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