Basic Information
| Provider Information | |||||||||
| NPI: | 1861720245 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHY SMILES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63407 130TH AVE | ||||||||
| Address2: | |||||||||
| City: | CLAREMONT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559244656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073196845 | ||||||||
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| Practice Location | |||||||||
| Address1: | 63407 130TH AVE | ||||||||
| Address2: | |||||||||
| City: | CLAREMONT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559244656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073196845 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2009 | ||||||||
| LastUpdateDate: | 11/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | KRUCKEBERG | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5073196845 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RDH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | Y | Agencies | Voluntary or Charitable |
No ID Information.