Provider Demographics
NPI:1912354531
Name:DBA SIMPLY TEETH
Entity type:Organization
Organization Name:DBA SIMPLY TEETH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DHAVAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-870-1111
Mailing Address - Street 1:905 E RAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2570
Mailing Address - Country:US
Mailing Address - Phone:847-870-1111
Mailing Address - Fax:847-749-4789
Practice Address - Street 1:905 E RAND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-2570
Practice Address - Country:US
Practice Address - Phone:847-870-1111
Practice Address - Fax:847-749-4789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190294061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty