Provider Demographics
NPI:1346486289
Name:PERFECT SMILE DENTAL SPA PARTNERSHIP
Entity Type:Organization
Organization Name:PERFECT SMILE DENTAL SPA PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:DOTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-528-3384
Mailing Address - Street 1:2155 W. ROSCOE STREET, 1N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6261
Mailing Address - Country:US
Mailing Address - Phone:773-528-3384
Mailing Address - Fax:773-528-3604
Practice Address - Street 1:2155 W. ROSCOE STREET, 1N
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6261
Practice Address - Country:US
Practice Address - Phone:773-528-3384
Practice Address - Fax:773-528-3604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-24
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190202401223G0001X
IL0190259861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty