MEDICARE: P&G SMILES LLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1962357665
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P&G SMILES LLC

Provider Business Mailing Address
First Line	:	9850 S MARYLAND PKWY STE 1
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89183-7148
Country	:	US
Telephone Number	:	702-703-0102
Fax Number	:	702-723-6773

Provider Business Practice Location Address
First Line	:	9850 S MARYLAND PKWY STE 1
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89183-7148
Country	:	US
Telephone Number	:	702-703-0102
Fax Number	:	702-723-6773

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	PRASHANTI BOLLU
Credential	:	D.M.D., M.S., M.B.A.
Telephone Number	:	617-849-0751

Provider Enumeration Date	:	02/27/2026
Last Update Date	:	02/27/2026

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Directions to “P&G SMILES LLC ” Practice Location

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