MEDICARE: SMILE CLINIQUE, PC

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	122300000X	Dentist	19025953	IL

General Provider Information

NPI Number	:	1184163495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE CLINIQUE, PC

Provider Business Mailing Address
First Line	:	2213 N IL ROUTE 83
Second Line	:
City	:	ROUND LAKE BEACH
State	:	IL
Zip	:	60073-4907
Country	:	US
Telephone Number	:	847-548-9527
Fax Number	:	847-548-9637

Provider Business Practice Location Address
First Line	:	2213 N IL ROUTE 83
Second Line	:
City	:	ROUND LAKE BEACH
State	:	IL
Zip	:	60073-4907
Country	:	US
Telephone Number	:	847-548-9527
Fax Number	:	847-548-9637

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RITU MALHOTRA
Credential	:	DDS
Telephone Number	:	847-548-9527

Provider Enumeration Date	:	02/20/2017
Last Update Date	:	02/20/2017

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