Healthcare Provider Details

I. General information

NPI: 1578807038
Provider Name (Legal Business Name): SMILE HEALTH SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 W ROBINHOOD DR SUITE 20
STOCKTON CA
95207-5512
US

IV. Provider business mailing address

1350 W ROBINHOOD DR SUITE 20
STOCKTON CA
95207-5512
US

V. Phone/Fax

Practice location:
  • Phone: 209-477-6700
  • Fax: 800-420-5168
Mailing address:
  • Phone: 209-477-6700
  • Fax: 800-420-5168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number35230
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number35230
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number35230
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number35230
License Number StateCA

VIII. Authorized Official

Name: RALPH A CALLENDER
Title or Position: MANAGING ORTHODONTIST
Credential: DDS
Phone: 209-477-6700