Provider Demographics
NPI:1952959074
Name:BEYOND SMILES OF PARK RIDGE
Entity Type:Organization
Organization Name:BEYOND SMILES OF PARK RIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LOWERY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-771-2605
Mailing Address - Street 1:650 N NORTHWEST HWY STE E
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-2554
Mailing Address - Country:US
Mailing Address - Phone:847-292-2700
Mailing Address - Fax:
Practice Address - Street 1:650 N NORTHWEST HWY STE E
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-2554
Practice Address - Country:US
Practice Address - Phone:847-292-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-02
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1912019142Medicaid