Healthcare Provider Details

I. General information

NPI: 1720210339
Provider Name (Legal Business Name): SMILE 4 LIFE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12253 E 104TH PLACE SUITE 105
COMMERCE CITY CO
80022
US

IV. Provider business mailing address

12253 E 104TH PLACE SUITE 105
COMMERCE CITY CO
80022
US

V. Phone/Fax

Practice location:
  • Phone: 303-853-8000
  • Fax: 303-288-2219
Mailing address:
  • Phone: 303-853-8000
  • Fax: 303-288-2219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number903823
License Number StateCO

VIII. Authorized Official

Name: JENNIE MACUMBER
Title or Position: PRESIDENT
Credential: R.D.H.
Phone: 303-829-9243