Healthcare Provider Details

I. General information

NPI: 1619308566
Provider Name (Legal Business Name): KIDS SMILE INNOVATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2013
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5129 CLINTON DR
KOKOMO IN
46902-7136
US

IV. Provider business mailing address

110 SUMMERS DR
TIPTON IN
46072-8696
US

V. Phone/Fax

Practice location:
  • Phone: 765-617-4750
  • Fax:
Mailing address:
  • Phone: 765-617-4750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12008126A
License Number StateIN

VIII. Authorized Official

Name: MS. APRIL D SPIVEY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 767-617-4750