Healthcare Provider Details

I. General information

NPI: 1699071845
Provider Name (Legal Business Name): THE EXTRA SMILE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 GREYHOUND PASS SUITE #B
CARMEL IN
46032-5027
US

IV. Provider business mailing address

1610 GREYHOUND PASS SUITE #B
CARMEL IN
46032-5027
US

V. Phone/Fax

Practice location:
  • Phone: 317-705-5800
  • Fax:
Mailing address:
  • Phone: 317-705-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12009970
License Number StateIN

VIII. Authorized Official

Name: DR. TIMOTHY J. HOFTIEZER
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 317-705-5800