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General NPI Number Information
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NPI Number | 1679891139
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Entity Type | Organization
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Legal Business Name | BROOKFIELD SMILES INC.
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Dates
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Enumeration Date | 05/08/2010
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Last Update Date | 05/08/2010
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Provider Practice Location Address
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Address Line | 8908 OGDEN AVE
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City | BROOKFIELD
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State | IL
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Zip | 60513-2006
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Country | US
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Telephone | 708-485-7710
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Fax | 708-485-7724
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Provider Business Mailing Address
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Address Line | 8908 OGDEN AVE
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City | BROOKFIELD
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State | IL
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Zip | 60513-2006
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Country | US
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Telephone | 708-485-7710
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Fax | 708-485-7724
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PAYAL SHAH
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Credential | D.D.S.
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Telephone | 708-485-7710
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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 | 019026277
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License Number State | IL
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