Healthcare Provider Details

I. General information

NPI: 1306314323
Provider Name (Legal Business Name): CR SMILES - MERIDIAN DENTAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W CAYUSE CREEK DR #100
MERIDIAN ID
83646
US

IV. Provider business mailing address

8285 W UNION HILLS DR #103
GLENDALE AZ
85308
US

V. Phone/Fax

Practice location:
  • Phone: 208-893-5435
  • Fax: 208-884-8915
Mailing address:
  • Phone: 623-362-8200
  • Fax: 623-979-7364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CALVIN C BROWN JR.
Title or Position: SOLE MEMBER
Credential: DDS
Phone: 248-798-7708