Provider Demographics
NPI:1689569931
Name:KLEAN SMILES SOUTHPORT PLLC
Entity type:Organization
Organization Name:KLEAN SMILES SOUTHPORT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NILAY
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-348-5758
Mailing Address - Street 1:313 W WOLF POINT PLZ UNIT 4302
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-8913
Mailing Address - Country:US
Mailing Address - Phone:269-348-5758
Mailing Address - Fax:
Practice Address - Street 1:3712 N SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-6889
Practice Address - Country:US
Practice Address - Phone:269-348-5758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental