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General NPI Number Information
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NPI Number | 1295968121
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Entity Type | Organization
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Legal Business Name | SMILE LEE FACES
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Dates
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Enumeration Date | 08/26/2009
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Last Update Date | 08/26/2009
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Provider Practice Location Address
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Address Line | 4197 S ARCHER AVE
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City | CHICAGO
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State | IL
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Zip | 60632
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Country | US
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Telephone | 773-376-9999
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Fax | 773-376-9990
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Provider Business Mailing Address
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Address Line | 4197 S ARCHER AVE
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City | CHICAGO
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State | IL
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Zip | 60632
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Country | US
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Telephone | 773-376-9999
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Fax | 773-376-9990
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. ANDREA LACAYO
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Credential | DDS
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Telephone | 773-376-9999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 019022928
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License Number State | IL
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