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General NPI Number Information
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NPI Number | 1598197105
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Entity Type | Organization
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Legal Business Name | COUNTRYWIDE SMILES P.C.
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Dates
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Enumeration Date | 08/06/2013
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Last Update Date | 08/06/2013
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Provider Practice Location Address
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Address Line | 110 S STATE ST
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City | ANNAWAN
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State | IL
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Zip | 61234-9716
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Country | US
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Telephone | 309-935-6126
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Fax |
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Provider Business Mailing Address
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Address Line | 501 DODGE ST
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City | KEWANEE
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State | IL
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Zip | 61443-3258
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Country | US
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Telephone | 773-733-6344
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BOGDAN MIHAI TARAN
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Credential | D.D.S.
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Telephone | 773-733-6344
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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 | 019027941
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License Number State | IL
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