Healthcare Provider Details

I. General information

NPI: 1740719004
Provider Name (Legal Business Name): SMILE, IT'S HEALTHY L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 SHAWNEE MISSION PARKWAY SUITE 208
FAIRWAY KS
66205
US

IV. Provider business mailing address

4400 SHAWNEE MISSION PKWY STE 208
FAIRWAY KS
66205-2518
US

V. Phone/Fax

Practice location:
  • Phone: 913-254-4065
  • Fax:
Mailing address:
  • Phone: 913-254-4065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARK MCDOUGALD
Title or Position: PRESIDENT
Credential:
Phone: 913-254-4065