Basic Information
| Provider Information | |||||||||
| NPI: | 1295149334 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SMILES DENTAL GROUP, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 OCEAN BEACH HWY | ||||||||
| Address2: | STE 110 | ||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986324080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039811841 | ||||||||
| FaxNumber: | 5039817334 | ||||||||
| Practice Location | |||||||||
| Address1: | 1018 N BOONES FERRY RD | ||||||||
| Address2: | |||||||||
| City: | WOODBURN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970719602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039811841 | ||||||||
| FaxNumber: | 5039817334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2014 | ||||||||
| LastUpdateDate: | 06/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2069196578 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA, MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | D8230 | OR | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
No ID Information.