Healthcare Provider Details

I. General information

NPI: 1417134560
Provider Name (Legal Business Name): MOBILE SMILES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3419 N GERONIMO AVE
TUCSON AZ
85705-3611
US

IV. Provider business mailing address

3419 N GERONIMO AVE
TUCSON AZ
85705-3611
US

V. Phone/Fax

Practice location:
  • Phone: 520-904-2211
  • Fax:
Mailing address:
  • Phone: 520-904-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5035
License Number StateAZ

VIII. Authorized Official

Name: MS. LESLIE L KURTAK
Title or Position: PRESIDENT
Credential: RDH
Phone: 520-904-2211