MEDICARE: CLEAR SMILE CENTER, 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	122300000X	Dentist	060011269	IL

General Provider Information

NPI Number	:	1912318700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAR SMILE CENTER, P.C.

Provider Business Mailing Address
First Line	:	1146 OXFORD RD
Second Line	:
City	:	DEERFIELD
State	:	IL
Zip	:	60015-3325
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	332 SKOKIE VALLEY RD
Second Line	:
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-4415
Country	:	US
Telephone Number	:	224-249-9500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HEEKYOUNG JO
Credential	:
Telephone Number	:	847-476-4050

Provider Enumeration Date	:	05/14/2014
Last Update Date	:	12/18/2014

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