Healthcare Provider Details

I. General information

NPI: 1366797748
Provider Name (Legal Business Name): SMILE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 1ST ST SE APT 603
WASHINGTON DC
20003-4712
US

IV. Provider business mailing address

736 BLEAK HILL PL
UPPER MARLBORO MD
20774-8863
US

V. Phone/Fax

Practice location:
  • Phone: 615-480-5562
  • Fax:
Mailing address:
  • Phone: 615-480-5562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDEN1000983
License Number State

VIII. Authorized Official

Name: DR. KEVIN C. GRANGER
Title or Position: MANAGING MEMBER/OWNER
Credential: DDS
Phone: 615-480-5562