Provider Demographics
NPI:1285138776
Name:SMILE LEAGUE DENTAL
Entity type:Organization
Organization Name:SMILE LEAGUE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MOROLAYO
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUYEMI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:571-398-9168
Mailing Address - Street 1:3587 HENNEPIN DR # D
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-9205
Mailing Address - Country:US
Mailing Address - Phone:815-782-6243
Mailing Address - Fax:
Practice Address - Street 1:3587 HENNEPIN DR # D
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-9205
Practice Address - Country:US
Practice Address - Phone:815-782-6243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031102122300000X, 1223G0001X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty