Healthcare Provider Details

I. General information

NPI: 1578038162
Provider Name (Legal Business Name): SMILE DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 CANAL BLVD
THIBODAUX LA
70301-4509
US

IV. Provider business mailing address

205 ABBY LAKE DR
THIBODAUX LA
70301-1633
US

V. Phone/Fax

Practice location:
  • Phone: 985-446-3855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: RENEE BIONDO
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 985-446-3855