Provider Demographics
NPI:1386035467
Name:BEAUTIFUL SMILES MOBILE DENTISTRY, LLC
Entity Type:Organization
Organization Name:BEAUTIFUL SMILES MOBILE DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LEONOR
Authorized Official - Middle Name:CECILIA
Authorized Official - Last Name:VILLALTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-722-4565
Mailing Address - Street 1:2547 W SPRINGFIELD AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2820
Mailing Address - Country:US
Mailing Address - Phone:217-552-8503
Mailing Address - Fax:
Practice Address - Street 1:2547 W SPRINGFIELD AVE
Practice Address - Street 2:APT 2
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2820
Practice Address - Country:US
Practice Address - Phone:217-552-8503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029681305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization