Healthcare Provider Details

I. General information

NPI: 1689047904
Provider Name (Legal Business Name): SMILE COMPANY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 W EMERALD ST
BOISE ID
83704-8736
US

IV. Provider business mailing address

2275 S EAGLE RD STE 140
MERIDIAN ID
83642-2620
US

V. Phone/Fax

Practice location:
  • Phone: 208-893-5000
  • Fax: 208-922-6057
Mailing address:
  • Phone: 208-888-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTT W. GRANT
Title or Position: PRESIDENT
Credential: DMD
Phone: 208-888-2000