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General NPI Number Information
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NPI Number | 1780834580
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Entity Type | Individual
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Provider Name | RANDI ELYN SMULSON 019027653
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Gender | Female
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Dates
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Enumeration Date | 09/29/2008
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Last Update Date | 02/02/2009
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Provider Practice Location Address
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Address Line | 1725 W NORTH AVE SUITE 102
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City | CHICAGO
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State | IL
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Zip | 60622-2188
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Country | US
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Telephone | 773-227-1048
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Fax | 773-227-3218
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Provider Business Mailing Address
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Address Line | 1725 W NORTH AVE SUITE 102
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City | CHICAGO
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State | IL
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Zip | 60622-2188
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Country | US
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Telephone | 773-227-1048
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Fax | 773-227-3218
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 019027653
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019027653
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License Number State | IL
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