Healthcare Provider Details

I. General information

NPI: 1033620570
Provider Name (Legal Business Name): SMILE DENTAL CENTRALIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W SNEED ST
CENTRALIA MO
65240-1375
US

IV. Provider business mailing address

PO BOX 306
MOBERLY MO
65270-0306
US

V. Phone/Fax

Practice location:
  • Phone: 573-682-5616
  • Fax:
Mailing address:
  • Phone: 660-263-6642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE SUE POWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 660-263-6642