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General NPI Number Information
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NPI Number | 1508076274
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Entity Type | Organization
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Legal Business Name | FAMILY SMILES P.C.
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 08/04/2009
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Provider Practice Location Address
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Address Line | 5240 N PULASKI RD SUITE I
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City | CHICAGO
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State | IL
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Zip | 60630-1750
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Country | US
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Telephone | 773-866-0041
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Fax | 773-866-0045
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Provider Business Mailing Address
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Address Line | 5240 N PULASKI RD SUITE I
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City | CHICAGO
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State | IL
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Zip | 60630-1750
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Country | US
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Telephone | 773-866-0041
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Fax | 773-866-0045
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Authorized Official
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Title or Position | VICE-PRESIDENT
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Name | ALI NEMATOLLAHI
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Credential | D.D.S.
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Telephone | 773-866-0041
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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 | 019022805
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License Number State | IL
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