Healthcare Provider Details

I. General information

NPI: 1619283850
Provider Name (Legal Business Name): SMILES FOR LIFE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 CIDER HILL RD
EXETER ME
04435-3030
US

IV. Provider business mailing address

195 CIDER HILL RD
EXETER ME
04435-3030
US

V. Phone/Fax

Practice location:
  • Phone: 207-379-2605
  • Fax:
Mailing address:
  • Phone: 207-379-2605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2521
License Number StateME

VIII. Authorized Official

Name: STORMY COLBATH
Title or Position: PRESIDENT
Credential: RDH
Phone: 207-379-2605