Provider Demographics
NPI:1619491610
Name:SPARKLING SMILES FAMILY DENTAL
Entity Type:Organization
Organization Name:SPARKLING SMILES FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ESAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JUMANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-755-2400
Mailing Address - Street 1:2400 CHICAGO RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-4160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 CHICAGO RD
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-4160
Practice Address - Country:US
Practice Address - Phone:708-755-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental