Provider Demographics
NPI:1306365234
Name:GRACEFUL SMILES DENTAL
Entity Type:Organization
Organization Name:GRACEFUL SMILES DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-414-3560
Mailing Address - Street 1:3520 CHANCERY LN
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110-3467
Mailing Address - Country:US
Mailing Address - Phone:847-414-3560
Mailing Address - Fax:
Practice Address - Street 1:615 S RANDALL RD STE 110
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1564
Practice Address - Country:US
Practice Address - Phone:847-414-3560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027466261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental