Provider Demographics
NPI:1407005879
Name:PROMISE HEALTHCARE NFP
Entity Type:Organization
Organization Name:PROMISE HEALTHCARE NFP
Other - Org Name:SMILEHEALTHY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTAL PROGRAMS ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROVEE
Authorized Official - Middle Name:
Authorized Official - Last Name:FABI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-403-5404
Mailing Address - Street 1:819 BLOOMINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820
Mailing Address - Country:US
Mailing Address - Phone:217-359-4704
Mailing Address - Fax:217-403-5469
Practice Address - Street 1:819 BLOOMINGTON ROAD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820
Practice Address - Country:US
Practice Address - Phone:217-359-7404
Practice Address - Fax:217-403-5469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty