Provider Demographics
NPI:1598161432
Name:TIMELESS SMILES DENTAL
Entity Type:Organization
Organization Name:TIMELESS SMILES DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RHODES-GAYLES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-233-1900
Mailing Address - Street 1:10412 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2018
Mailing Address - Country:US
Mailing Address - Phone:773-233-1900
Mailing Address - Fax:773-233-9967
Practice Address - Street 1:10412 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2018
Practice Address - Country:US
Practice Address - Phone:773-233-1900
Practice Address - Fax:773-233-9967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023222122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty