Provider Demographics
NPI:1316375843
Name:STAR SMILE P.C.
Entity type:Organization
Organization Name:STAR SMILE P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LYUSHKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-385-6545
Mailing Address - Street 1:1311 N GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4452
Mailing Address - Country:US
Mailing Address - Phone:815-385-6545
Mailing Address - Fax:
Practice Address - Street 1:1311 N GREEN ST
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4452
Practice Address - Country:US
Practice Address - Phone:815-385-6545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STAR SMILE P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028012122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========2OtherDENTIST