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General NPI Number Information
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NPI Number | 1407112980
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Entity Type | Organization
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Legal Business Name | THE HEART THAT SMILES MOBILE DENTISTS
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Dates
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Enumeration Date | 04/09/2012
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Last Update Date | 04/09/2012
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Provider Practice Location Address
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Address Line | 2060 RIDGE RD N, SUITE 3 LOWER LEVEL
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City | HOMEWOOD
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State | IL
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Zip | 60430-1780
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Country | US
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Telephone | 312-391-1913
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Fax |
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Provider Business Mailing Address
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Address Line | 2060 RIDGE RD N, SUITE 3 LOWER LEVEL
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City | HOMEWOOD
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State | IL
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Zip | 60430-1780
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. LATOI RAPHAEL THOMAS
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Credential | D.D.S
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Telephone | 312-391-1913
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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 | 019028142
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License Number State | IL
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