Provider Demographics
NPI:1598197105
Name:COUNTRYWIDE SMILES P.C.
Entity Type:Organization
Organization Name:COUNTRYWIDE SMILES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOGDAN
Authorized Official - Middle Name:MIHAI
Authorized Official - Last Name:TARAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-733-6344
Mailing Address - Street 1:501 DODGE ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-3258
Mailing Address - Country:US
Mailing Address - Phone:773-733-6344
Mailing Address - Fax:
Practice Address - Street 1:110 S STATE ST
Practice Address - Street 2:
Practice Address - City:ANNAWAN
Practice Address - State:IL
Practice Address - Zip Code:61234-9716
Practice Address - Country:US
Practice Address - Phone:309-935-6126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190279411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty