Healthcare Provider Details

I. General information

NPI: 1811683097
Provider Name (Legal Business Name): SMILES 4 KIDS JEROME PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 EAST ROSE ST.
JEROME ID
83338
US

IV. Provider business mailing address

PO BOX 6075
TWIN FALLS ID
83303-6075
US

V. Phone/Fax

Practice location:
  • Phone: 208-324-7415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LEANN SPORIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-734-7415