Healthcare Provider Details

I. General information

NPI: 1609249804
Provider Name (Legal Business Name): LITTLE BIG SMILES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 E 350
RAYTOWN MO
64133-5717
US

IV. Provider business mailing address

9000 E 350
RAYTOWN MO
64133-5717
US

V. Phone/Fax

Practice location:
  • Phone: 816-674-9796
  • Fax:
Mailing address:
  • Phone: 816-674-9796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2010033385
License Number StateMO

VIII. Authorized Official

Name: DR. BENJAMIN G WILSON
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 970-901-9865