Provider Demographics
NPI:1174253272
Name:HOLY FAMILY HEALTHY SMILES DBA NORTHSHORE SMILES FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:HOLY FAMILY HEALTHY SMILES DBA NORTHSHORE SMILES FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNNASSERY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-307-3240
Mailing Address - Street 1:832 PONY LN
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062
Mailing Address - Country:US
Mailing Address - Phone:708-307-3240
Mailing Address - Fax:
Practice Address - Street 1:830 EAST RAND ROAD SUITE 11
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056
Practice Address - Country:US
Practice Address - Phone:224-306-9060
Practice Address - Fax:224-306-9059
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLY FAMILY HEALTHY SMILES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty