Healthcare Provider Details

I. General information

NPI: 1083245484
Provider Name (Legal Business Name): SMILES ON THE GO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 FRANCIS STREET SUITE 202 UNIT D
LONGMONT CO
80501
US

IV. Provider business mailing address

1361 FRANCIS STREET SUITE 202 UNIT D
LONGMONT CO
80501
US

V. Phone/Fax

Practice location:
  • Phone: 720-592-6895
  • Fax:
Mailing address:
  • Phone: 720-592-6895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: ANNMARIE CHADDIC
Title or Position: REGISTERED DENTAL HYGIENIST
Credential: RDH
Phone: 720-592-6895