MEDICARE: AESTHETIC SMILES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D3877	ID

General Provider Information

NPI Number	:	1164684312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AESTHETIC SMILES

Provider Business Mailing Address
First Line	:	4795 N SUMMIT WAY STE 120
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5017
Country	:	US
Telephone Number	:	208-888-0662
Fax Number	:	208-888-0863

Provider Business Practice Location Address
First Line	:	4795 N SUMMIT WAY STE 120
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5017
Country	:	US
Telephone Number	:	208-888-0662
Fax Number	:	208-888-0863

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. WADE AUSTEN PILLING
Credential	:	DMD
Telephone Number	:	208-888-0662

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	05/01/2017

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Directions to “AESTHETIC SMILES ” Practice Location

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