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General NPI Number Information
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NPI Number | 1689908535
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Entity Type | Organization
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Legal Business Name | SMD ORTHODONTICS
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Dates
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Enumeration Date | 09/24/2009
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Last Update Date | 09/24/2009
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Provider Practice Location Address
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Address Line | 300 S MCLEAN BLVD STE M
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City | ELGIN
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State | IL
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Zip | 60123-1023
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Country | US
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Telephone | 847-531-5250
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Fax | 847-531-5270
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Provider Business Mailing Address
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Address Line | 300 S MCLEAN BLVD STE M
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City | ELGIN
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State | IL
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Zip | 60123-1023
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Country | US
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Telephone | 847-531-5250
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Fax | 847-531-5270
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Authorized Official
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Title or Position | PRESIDENT/DENTIST
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Name | DR. OSMAR RODRIGUEZ
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Credential | D.D.S.
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Telephone | 847-531-5250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 021001216
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 021001216
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License Number State | IL
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