MEDICARE: SMILE CENTER, INC.

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	261QD0000X	Dental Clinic/Center	3343	OK

General Provider Information

NPI Number	:	1669621629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE CENTER, INC.

Provider Business Mailing Address
First Line	:	4528 S SHERIDAN RD
Second Line	:	SUITE 112
City	:	TULSA
State	:	OK
Zip	:	74145-1140
Country	:	US
Telephone Number	:	918-664-3366
Fax Number	:	918-664-0933

Provider Business Practice Location Address
First Line	:	4528 S SHERIDAN RD
Second Line	:	SUITE 112
City	:	TULSA
State	:	OK
Zip	:	74145-1140
Country	:	US
Telephone Number	:	918-664-3366
Fax Number	:	918-664-0933

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LARRY LEE WILLIAMS
Credential	:	D.D.S.
Telephone Number	:	918-664-3366

Provider Enumeration Date	:	09/15/2008
Last Update Date	:	09/15/2008

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