MEDICARE: THAT CERTAIN SMILE

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

General Provider Information

NPI Number	:	1396958864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THAT CERTAIN SMILE

Provider Business Mailing Address
First Line	:	4511 S LAKE PARK AVE 1N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-1461
Country	:	US
Telephone Number	:	708-218-3296
Fax Number	:	708-575-0401

Provider Business Practice Location Address
First Line	:	4511 S LAKE PARK AVE 1N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-1461
Country	:	US
Telephone Number	:	708-218-3296
Fax Number	:	708-575-0401

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TINA MICHELL HARRIS
Credential	:	DDS
Telephone Number	:	708-218-3296

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	12/26/2013

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