Healthcare Provider Details

I. General information

NPI: 1740758028
Provider Name (Legal Business Name): SILVER CITY ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2018
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 E 32ND ST
SILVER CITY NM
88061-7252
US

IV. Provider business mailing address

1455 S 20TH AVE
SAFFORD AZ
85546-4053
US

V. Phone/Fax

Practice location:
  • Phone: 928-428-5555
  • Fax:
Mailing address:
  • Phone: 928-428-5555
  • Fax:

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: DR. BRADLEY R. SMITH
Title or Position: OWNER
Credential: DMD, DHSC
Phone: 480-612-7115