MEDICARE: SMILE SUPPORT LTD

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

General Provider Information

NPI Number	:	1316131311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE SUPPORT LTD

Provider Business Mailing Address
First Line	:	1507 E 53RD ST
Second Line	:	UNIT 166
City	:	CHICAGO
State	:	IL
Zip	:	60615-4509
Country	:	US
Telephone Number	:	773-412-0094
Fax Number	:

Provider Business Practice Location Address
First Line	:	1507 E 53RD ST
Second Line	:	UNIT 166
City	:	CHICAGO
State	:	IL
Zip	:	60615-4509
Country	:	US
Telephone Number	:	773-412-0094
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. TWANA EDWARDS
Credential	:	DDS
Telephone Number	:	773-412-0094

Provider Enumeration Date	:	09/01/2007
Last Update Date	:	09/01/2007

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Directions to “SMILE SUPPORT LTD ” Practice Location

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