MEDICARE: PERFECT SMILE P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019026329	IL

General Provider Information

NPI Number	:	1083885271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFECT SMILE P.C.

Provider Business Mailing Address
First Line	:	1624 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1214
Country	:	US
Telephone Number	:	773-275-5600
Fax Number	:	773-275-5868

Provider Business Practice Location Address
First Line	:	1624 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1214
Country	:	US
Telephone Number	:	773-275-5600
Fax Number	:	773-275-5868

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. SALMAN UMAR POOTHAWALA
Credential	:	DDS
Telephone Number	:	773-275-5600

Provider Enumeration Date	:	03/17/2008
Last Update Date	:	03/17/2008

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