Healthcare Provider Details

I. General information

NPI: 1013598739
Provider Name (Legal Business Name): IMAGINE SMILES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 04/15/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13205 REAMS RD UNIT 164
WINDERMERE FL
34786
US

IV. Provider business mailing address

5259 ARIVA DR APT 101
LAKELAND FL
33812-4436
US

V. Phone/Fax

Practice location:
  • Phone: 864-906-6179
  • Fax:
Mailing address:
  • Phone: 864-906-6179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: THAO LATHAM
Title or Position: OWNER
Credential: DMD
Phone: 864-906-6179