Healthcare Provider Details

I. General information

NPI: 1013101419
Provider Name (Legal Business Name): SOUTHWEST SMILES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2487 S GILBERT RD STE 105
GILBERT AZ
85295-2800
US

IV. Provider business mailing address

11512 E QUEENSBOROUGH AVE
MESA AZ
85212-4091
US

V. Phone/Fax

Practice location:
  • Phone: 480-732-1888
  • Fax:
Mailing address:
  • Phone: 480-951-6598
  • Fax: 480-452-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5585
License Number StateAZ

VIII. Authorized Official

Name: KELLY MARIE POVAR
Title or Position: MANAGING MEMBER
Credential: RDH
Phone: 480-951-6598