Healthcare Provider Details

I. General information

NPI: 1629243571
Provider Name (Legal Business Name): SMILE INNOVATIONS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6323 S RURAL RD STE 101
TEMPE AZ
85283-2933
US

IV. Provider business mailing address

6323 S RURAL RD STE 101
TEMPE AZ
85283-2933
US

V. Phone/Fax

Practice location:
  • Phone: 480-820-7777
  • Fax: 480-820-7774
Mailing address:
  • Phone: 480-820-7777
  • Fax: 480-820-7774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. BOYD PATUMMAS
Title or Position: DENTIST/VICE PRESIDENT
Credential: D.M.D
Phone: 480-820-7777