Provider Demographics
NPI:1720433915
Name:SKYLINE SMILES OF ROSCOE VILLAGE LLC
Entity Type:Organization
Organization Name:SKYLINE SMILES OF ROSCOE VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPAK
Authorized Official - Middle Name:
Authorized Official - Last Name:NEDUVELIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-759-1120
Mailing Address - Street 1:2125 W ROSCOE ST
Mailing Address - Street 2:UNIT A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6219
Mailing Address - Country:US
Mailing Address - Phone:312-759-1120
Mailing Address - Fax:312-624-9217
Practice Address - Street 1:2125 W ROSCOE ST
Practice Address - Street 2:UNIT A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6219
Practice Address - Country:US
Practice Address - Phone:312-759-1120
Practice Address - Fax:312-624-9217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190279641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty