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General NPI Number Information
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NPI Number | 1346486289
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Entity Type | Organization
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Legal Business Name | PERFECT SMILE DENTAL SPA PARTNERSHIP
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Dates
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Enumeration Date | 12/24/2008
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Last Update Date | 12/24/2008
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Provider Practice Location Address
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Address Line | 2155 W. ROSCOE STREET, 1N
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City | CHICAGO
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State | IL
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Zip | 60618-6261
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Country | US
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Telephone | 773-528-3384
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Fax | 773-528-3604
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Provider Business Mailing Address
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Address Line | 2155 W. ROSCOE STREET, 1N
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City | CHICAGO
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State | IL
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Zip | 60618-6261
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Country | US
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Telephone | 773-528-3384
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Fax | 773-528-3604
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Authorized Official
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Title or Position | DENTIST/PARTNER
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Name | DR. TIMOTHY B DOTSON
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Credential | DDS
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Telephone | 773-528-3384
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019025986
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019020240
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License Number State | IL
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