Provider Demographics
NPI:1982121042
Name:BROWN ARCHER DENTAL PC
Entity Type:Organization
Organization Name:BROWN ARCHER DENTAL PC
Other - Org Name:SMILE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALIL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-788-9090
Mailing Address - Street 1:4893 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-3621
Mailing Address - Country:US
Mailing Address - Phone:773-788-9090
Mailing Address - Fax:
Practice Address - Street 1:4893 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632
Practice Address - Country:US
Practice Address - Phone:773-788-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190251351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1306916465Medicaid