Healthcare Provider Details

I. General information

NPI: 1255626826
Provider Name (Legal Business Name): HEALTHY SMILES MOBILE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2011
Last Update Date: 10/17/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16409 E 38TH ST CT S
INDEPENDENCE MO
64055
US

IV. Provider business mailing address

16409 E 38TH ST CT S
INDEPENDENCE MO
64055
US

V. Phone/Fax

Practice location:
  • Phone: 816-427-1164
  • Fax: 816-535-2184
Mailing address:
  • Phone: 816-463-2263
  • Fax: 816-463-2264

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: GAIL A LUSK
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 813-221-4038