Healthcare Provider Details

I. General information

NPI: 1386277291
Provider Name (Legal Business Name): SMILE STRAIGHT ORTHODONTICS-CENTRAL MS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W WOODROW WILSON AVE STE 400
JACKSON MS
39213-7697
US

IV. Provider business mailing address

5717 E THOMAS RD STE 110
SCOTTSDALE AZ
85251-7620
US

V. Phone/Fax

Practice location:
  • Phone: 769-230-1940
  • Fax: 601-292-6311
Mailing address:
  • Phone: 623-282-9959
  • Fax: 602-429-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TERESA ZWICKY
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 480-866-8811