Healthcare Provider Details

I. General information

NPI: 1639514045
Provider Name (Legal Business Name): SMILE DESIGN STUDIO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 S INTERNATIONAL PKWY SUITE 2271
LAKE MARY FL
32746-1405
US

IV. Provider business mailing address

1331 S INTERNATIONAL PKWY SUITE 2271
LAKE MARY FL
32746-1405
US

V. Phone/Fax

Practice location:
  • Phone: 407-804-0770
  • Fax: 407-804-0773
Mailing address:
  • Phone: 407-804-0770
  • Fax: 407-804-0773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN12688
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK A FALCO
Title or Position: PRESIDENT
Credential: DMD, MS
Phone: 407-804-0770