Provider Demographics
NPI:1669908695
Name:PRECIOUS SMILES DENTAL PC
Entity type:Organization
Organization Name:PRECIOUS SMILES DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIVYA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KRISHNA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:224-944-9399
Mailing Address - Street 1:732 N FAIRFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-8160
Mailing Address - Country:US
Mailing Address - Phone:847-740-4100
Mailing Address - Fax:
Practice Address - Street 1:732 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-8160
Practice Address - Country:US
Practice Address - Phone:847-740-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027134122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty