Provider Demographics
NPI:1447816616
Name:SOUTHWEST SMILING DENTAL P.C.
Entity type:Organization
Organization Name:SOUTHWEST SMILING DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIANJUN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-941-1010
Mailing Address - Street 1:836 S MILLER ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4207
Mailing Address - Country:US
Mailing Address - Phone:773-941-1010
Mailing Address - Fax:
Practice Address - Street 1:11141 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2329
Practice Address - Country:US
Practice Address - Phone:773-779-1606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
No126800000XDental ProvidersDental AssistantGroup - Single Specialty