Healthcare Provider Details

I. General information

NPI: 1952815003
Provider Name (Legal Business Name): SMILE DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 BONITA BEACH RD SE STE 301
BONITA SPRINGS FL
34135-4698
US

IV. Provider business mailing address

9491 CEDAR CREEK DR
BONITA SPRINGS FL
34135-7517
US

V. Phone/Fax

Practice location:
  • Phone: 239-319-2440
  • Fax:
Mailing address:
  • Phone: 954-649-5588
  • Fax: 954-649-5588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMANTA ANDISCO
Title or Position: MANAGER
Credential:
Phone: 239-319-2440