=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487962809
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SMILEMOBILE P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2010
-----------------------------------------------------
Last Update Date | 09/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8537 S CICERO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60652-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-582-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8537 S CICERO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60652-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHRISTOS A TSALIAGOS
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 773-582-6400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------