Provider Demographics
NPI:1780290676
Name:GREAT SMILE DENTAL PLLC
Entity type:Organization
Organization Name:GREAT SMILE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-945-1050
Mailing Address - Street 1:720 OSTERMAN AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4339
Mailing Address - Country:US
Mailing Address - Phone:847-945-1050
Mailing Address - Fax:847-940-0433
Practice Address - Street 1:720 OSTERMAN AVE STE 304
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4339
Practice Address - Country:US
Practice Address - Phone:847-945-1050
Practice Address - Fax:847-940-0433
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT SMILE DENTAL PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental