=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619613775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIGNATURE SMILE ARTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2022
-----------------------------------------------------
Last Update Date | 02/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18114 GOTTSCHALK AVE
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60430-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-799-5353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 S STATE ST UNIT 1401
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-345-3521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PRESIDENT
-----------------------------------------------------
Name | DR. ALEXANDER MICHAEL SHORE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 708-799-5353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------