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General NPI Number Information
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NPI Number | 1356683536
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Entity Type | Organization
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Legal Business Name | STAR SMILES ORTHODONTICS AND PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 03/26/2013
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Last Update Date | 10/30/2013
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Provider Practice Location Address
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Address Line | 148 E LAKE ST UNIT C
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1182
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Country | US
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Telephone | 630-980-8800
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Fax |
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Provider Business Mailing Address
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Address Line | 148 E LAKE ST UNIT C
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1182
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Country | US
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Telephone | 630-980-8800
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Fax |
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Authorized Official
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Title or Position | DDS
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Name | ANDRE JHAM
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Credential |
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Telephone | 630-980-8800
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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 | 019028919
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 019028920
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License Number State | IL
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