Provider Demographics
NPI:1942621925
Name:THE SMILE GROUP LLC
Entity Type:Organization
Organization Name:THE SMILE GROUP LLC
Other - Org Name:KOALA CENTER FOR SLEEP DISORDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:OWEN
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:216-973-0552
Mailing Address - Street 1:11825 STATE ROUTE 40
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8842
Mailing Address - Country:US
Mailing Address - Phone:309-282-8565
Mailing Address - Fax:309-265-0156
Practice Address - Street 1:111 N WABASH AVE
Practice Address - Street 2:SUITE 1412
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1903
Practice Address - Country:US
Practice Address - Phone:309-282-8565
Practice Address - Fax:309-265-0156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty