MEDICARE: KLEAN SMILES SOUTHPORT PLLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1689569931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KLEAN SMILES SOUTHPORT PLLC

Provider Business Mailing Address
First Line	:	3712 N SOUTHPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-6889
Country	:	US
Telephone Number	:	269-348-5758
Fax Number	:

Provider Business Practice Location Address
First Line	:	3712 N SOUTHPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-6889
Country	:	US
Telephone Number	:	269-348-5758
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NILAY PATEL
Credential	:	DDS
Telephone Number	:	269-348-5758

Provider Enumeration Date	:	06/09/2025
Last Update Date	:	12/12/2025

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