Provider Demographics
NPI:1265102487
Name:SMILES OF NORTHLAKE CORP
Entity type:Organization
Organization Name:SMILES OF NORTHLAKE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANSI
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-325-4395
Mailing Address - Street 1:32 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60164-2500
Mailing Address - Country:US
Mailing Address - Phone:708-562-1105
Mailing Address - Fax:
Practice Address - Street 1:32 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-2500
Practice Address - Country:US
Practice Address - Phone:732-325-4395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-18
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty