=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922375450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCHMIDT/FAITH ORTHODONTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2011
-----------------------------------------------------
Last Update Date | 11/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 E ALGONQUIN RD STE 216
-----------------------------------------------------
City | ALGONQUIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60102-9632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-854-1873
-----------------------------------------------------
Fax | 847-854-3975
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 E ALGONQUIN RD
-----------------------------------------------------
City | ALGONQUIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60102-9632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-854-1873
-----------------------------------------------------
Fax | 847-854-3975
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. DEANNE M SCHMIDT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-854-1873
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 248000457
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------