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General NPI Number Information
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NPI Number | 1306365234
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Entity Type | Organization
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Legal Business Name | GRACEFUL SMILES DENTAL
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Dates
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Enumeration Date | 09/12/2017
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Last Update Date | 09/12/2017
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Provider Practice Location Address
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Address Line | 615 S RANDALL RD STE 110
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City | SAINT CHARLES
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State | IL
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Zip | 60174-1564
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Country | US
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Telephone | 847-414-3560
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Fax |
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Provider Business Mailing Address
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Address Line | 3520 CHANCERY LN
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City | CARPENTERSVILLE
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State | IL
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Zip | 60110-3467
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Country | US
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Telephone | 847-414-3560
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | GEORGE MATHEW
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Credential | DDS
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Telephone | 847-414-3560
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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 | 019.027466
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License Number State | IL
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