Provider Demographics
NPI:1407112980
Name:THE HEART THAT SMILES MOBILE DENTISTS
Entity Type:Organization
Organization Name:THE HEART THAT SMILES MOBILE DENTISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LATOI
Authorized Official - Middle Name:RAPHAEL
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-391-1913
Mailing Address - Street 1:2060 RIDGE RD
Mailing Address - Street 2:N, SUITE 3 LOWER LEVEL
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-1780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2060 RIDGE RD
Practice Address - Street 2:N, SUITE 3 LOWER LEVEL
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1780
Practice Address - Country:US
Practice Address - Phone:312-391-1913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028142122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty