Provider Demographics
NPI:1013347160
Name:STAR SMILES ORTHODONTICS AND PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:STAR SMILES ORTHODONTICS AND PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTICS
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:JHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-384-3500
Mailing Address - Street 1:3012 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2940
Mailing Address - Country:US
Mailing Address - Phone:773-384-3500
Mailing Address - Fax:773-384-3963
Practice Address - Street 1:3012 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2940
Practice Address - Country:US
Practice Address - Phone:773-384-3500
Practice Address - Fax:773-384-3963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028920261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019028920Medicaid