Provider Demographics
NPI:1962891457
Name:SMILE DENTAL CENTER OF CHICAGO
Entity type:Organization
Organization Name:SMILE DENTAL CENTER OF CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PANOREA
Authorized Official - Middle Name:
Authorized Official - Last Name:TSILIMIGRAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-920-9970
Mailing Address - Street 1:25 E WASHINGTON ST STE 2027
Mailing Address - Street 2:2027
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1817
Mailing Address - Country:US
Mailing Address - Phone:312-920-9970
Mailing Address - Fax:312-920-9971
Practice Address - Street 1:25 E WASHINGTON ST
Practice Address - Street 2:2027
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1708
Practice Address - Country:US
Practice Address - Phone:312-920-9970
Practice Address - Fax:312-920-9971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021207122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004032Medicaid