MEDICARE: SMILE STUDIO OF MIDWEST CITY, PLLC

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	5981	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1223G0001X	OTHER	OK	DENTIST-GENERAL PRACTICE

General Provider Information

NPI Number	:	1316334832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE STUDIO OF MIDWEST CITY, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 30466
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73140-3466
Country	:	US
Telephone Number	:	405-737-5905
Fax Number	:	405-739-0328

Provider Business Practice Location Address
First Line	:	1908 S POST RD
Second Line	:	BUILDING 1
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-6600
Country	:	US
Telephone Number	:	405-737-5905
Fax Number	:	405-732-2109

Authorized Official
Title or Position	:	OWNER
Name	:	DR. EDWARD HARROZ III
Credential	:	DDS
Telephone Number	:	405-737-5905

Provider Enumeration Date	:	04/22/2015
Last Update Date	:	08/04/2015

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