Healthcare Provider Details

I. General information

NPI: 1366711087
Provider Name (Legal Business Name): PEDIATRIC SMILES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2011
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 N 400 W SUITE A-4
OREM UT
84057-1909
US

IV. Provider business mailing address

167 N 400 W SUITE A-4
OREM UT
84057-1909
US

V. Phone/Fax

Practice location:
  • Phone: 801-224-0861
  • Fax: 801-804-5899
Mailing address:
  • Phone: 801-224-0861
  • Fax: 801-804-5899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8012319
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ADAM NICHOLAS SHEPHERD
Title or Position: OWNER/MEMBER
Credential: DDS
Phone: 18012240861