Provider Demographics
NPI:1740649193
Name:SMILE MORE DENTAL 3 CORP
Entity type:Organization
Organization Name:SMILE MORE DENTAL 3 CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMI
Authorized Official - Middle Name:MOHAMED
Authorized Official - Last Name:DIAB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-451-7264
Mailing Address - Street 1:1480 N ORCHARD RD
Mailing Address - Street 2:#104
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-7939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1480 N ORCHARD RD
Practice Address - Street 2:#104
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-7939
Practice Address - Country:US
Practice Address - Phone:630-343-0543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-14
Last Update Date:2016-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027963261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019027963Medicaid