Healthcare Provider Details

I. General information

NPI: 1417136870
Provider Name (Legal Business Name): SMALL SMILES DENTAL CENTER OF WEST COLUMBUS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4666 W BROAD ST
COLUMBUS OH
43228-1611
US

IV. Provider business mailing address

201 W 8TH ST SUITE 810
PUEBLO CO
81003-3038
US

V. Phone/Fax

Practice location:
  • Phone: 614-851-0409
  • Fax:
Mailing address:
  • Phone: 719-562-4447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. TRUDY WILLIAMS
Title or Position: DIRECTOR, LICENSING & CREDENTIALING
Credential:
Phone: 615-750-0342