Provider Demographics
NPI:1396958864
Name:THAT CERTAIN SMILE
Entity type:Organization
Organization Name:THAT CERTAIN SMILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MICHELL
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-218-3296
Mailing Address - Street 1:4511 S LAKE PARK AVE 1N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-1461
Mailing Address - Country:US
Mailing Address - Phone:708-218-3296
Mailing Address - Fax:708-575-0401
Practice Address - Street 1:4511 S LAKE PARK AVE 1N
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-1461
Practice Address - Country:US
Practice Address - Phone:708-218-3296
Practice Address - Fax:708-575-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty