Provider Demographics
NPI:1114190675
Name:SMILE AVENUE DENTAL PC
Entity Type:Organization
Organization Name:SMILE AVENUE DENTAL PC
Other - Org Name:BRICKYARD FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYUI HYUN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-520-5545
Mailing Address - Street 1:2620 N NARRAGANSETT AVE # B13
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1081
Mailing Address - Country:US
Mailing Address - Phone:312-520-5545
Mailing Address - Fax:
Practice Address - Street 1:2620 N NARRAGANSETT AVE # B13
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1081
Practice Address - Country:US
Practice Address - Phone:312-520-5545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2008-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190271151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty