Provider Demographics
NPI:1235675919
Name:LUCKY SMILE DENTAL LLC
Entity Type:Organization
Organization Name:LUCKY SMILE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:UPPALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:484-241-1888
Mailing Address - Street 1:367 SATINWOOD TER
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-4605
Mailing Address - Country:US
Mailing Address - Phone:484-241-1888
Mailing Address - Fax:
Practice Address - Street 1:35 HUNTINGTON LN
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-6908
Practice Address - Country:US
Practice Address - Phone:847-229-1700
Practice Address - Fax:847-947-8705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029466122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty