Provider Demographics
NPI:1093057556
Name:SKYLINE SMILES LLC
Entity Type:Organization
Organization Name:SKYLINE SMILES LLC
Other - Org Name:SKYLINE SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPAK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:NEDUVELIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-710-3883
Mailing Address - Street 1:1017 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607
Mailing Address - Country:US
Mailing Address - Phone:312-759-1120
Mailing Address - Fax:
Practice Address - Street 1:1017 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607
Practice Address - Country:US
Practice Address - Phone:312-759-1120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190279641223G0001X
IL0190279661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty