Provider Demographics
NPI:1689731481
Name:SMILE STREET DENTAL
Entity Type:Organization
Organization Name:SMILE STREET DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROCIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-439-2731
Mailing Address - Street 1:3587 HENNEPIN DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431
Mailing Address - Country:US
Mailing Address - Phone:815-439-2731
Mailing Address - Fax:815-439-2724
Practice Address - Street 1:3587 HENNEPIN DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431
Practice Address - Country:US
Practice Address - Phone:815-439-2731
Practice Address - Fax:815-439-2724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty