Provider Demographics
NPI:1699214155
Name:SHINING SMILES RIVERSIDE INC.
Entity Type:Organization
Organization Name:SHINING SMILES RIVERSIDE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MILAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NOURAHMADI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-217-2223
Mailing Address - Street 1:210 N BOLINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2386
Mailing Address - Country:US
Mailing Address - Phone:630-972-4010
Mailing Address - Fax:
Practice Address - Street 1:2720 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1738
Practice Address - Country:US
Practice Address - Phone:708-321-1023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty