Provider Demographics
NPI:1467540518
Name:BEVERLY SHORES SMILE CENTER
Entity Type:Organization
Organization Name:BEVERLY SHORES SMILE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOWALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-233-3535
Mailing Address - Street 1:10142 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1928
Mailing Address - Country:US
Mailing Address - Phone:773-233-3535
Mailing Address - Fax:773-238-5713
Practice Address - Street 1:10142 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1928
Practice Address - Country:US
Practice Address - Phone:773-233-3535
Practice Address - Fax:773-238-5713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty