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General NPI Number Information
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NPI Number | 1942600523
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Entity Type | Organization
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Legal Business Name | WEST LOOP SMILE STUDIO
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Dates
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Enumeration Date | 09/02/2014
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Last Update Date | 09/02/2014
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Provider Practice Location Address
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Address Line | 955 W MONROE ST
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City | CHICAGO
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State | IL
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Zip | 60607-2811
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Country | US
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Telephone | 312-994-4460
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Fax |
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Provider Business Mailing Address
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Address Line | 955 W MONROE ST
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City | CHICAGO
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State | IL
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Zip | 60607-2811
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/DENTIST
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Name | DR. OZZIE SMITH III
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Credential | DDS
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Telephone | 312-994-4460
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019026734
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License Number State | IL
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