Healthcare Provider Details

I. General information

NPI: 1184389272
Provider Name (Legal Business Name): SMILE STRAIGHT ORTHODONTICS - JACKSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7040 OLD CANTON RD
RIDGELAND MS
39157-1035
US

IV. Provider business mailing address

5717 E THOMAS RD STE 100
SCOTTSDALE AZ
85251-7620
US

V. Phone/Fax

Practice location:
  • Phone: 601-368-6635
  • Fax:
Mailing address:
  • Phone: 480-866-8811
  • 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: MGR
Credential:
Phone: 480-866-8811