Provider Demographics
NPI:1730574641
Name:SMILE CENTER OF BROOKFIELD
Entity type:Organization
Organization Name:SMILE CENTER OF BROOKFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PAUNESCU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-485-7754
Mailing Address - Street 1:9144 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1304
Mailing Address - Country:US
Mailing Address - Phone:708-485-7754
Mailing Address - Fax:708-485-6454
Practice Address - Street 1:9144 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513-1304
Practice Address - Country:US
Practice Address - Phone:708-485-7754
Practice Address - Fax:708-485-6454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190240771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty