Provider Demographics
NPI:1780834580
Name:SMULSON, RANDI ELYN (019027653)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:ELYN
Last Name:SMULSON
Suffix:
Gender:F
Credentials:019027653
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W NORTH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2188
Mailing Address - Country:US
Mailing Address - Phone:773-227-1048
Mailing Address - Fax:773-227-3218
Practice Address - Street 1:1725 W NORTH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2188
Practice Address - Country:US
Practice Address - Phone:773-227-1048
Practice Address - Fax:773-227-3218
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027653122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist