Healthcare Provider Details

I. General information

NPI: 1659824373
Provider Name (Legal Business Name): SMILE AURORA DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 S PEORIA ST STE A
AURORA CO
80014-3182
US

IV. Provider business mailing address

2900 S PEORIA ST STE A
AURORA CO
80014-3182
US

V. Phone/Fax

Practice location:
  • Phone: 310-562-9585
  • Fax: 303-368-3631
Mailing address:
  • Phone: 303-368-3636
  • Fax: 303-368-3631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number00202980
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number59646
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number00202980
License Number StateCO

VIII. Authorized Official

Name: HANA KIM
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 310-562-9585