Provider Demographics
NPI:1891264644
Name:SMILE ON OF NORTH SHORE, PC
Entity Type:Organization
Organization Name:SMILE ON OF NORTH SHORE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PONCZA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS DABDSM
Authorized Official - Phone:224-282-8939
Mailing Address - Street 1:707 LAKE COOK RD.
Mailing Address - Street 2:SUITE 121
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015
Mailing Address - Country:US
Mailing Address - Phone:224-282-8939
Mailing Address - Fax:773-337-4988
Practice Address - Street 1:707 LAKE COOK RD.
Practice Address - Street 2:SUITE 121
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015
Practice Address - Country:US
Practice Address - Phone:224-282-8939
Practice Address - Fax:773-337-4988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty