Healthcare Provider Details

I. General information

NPI: 1164228318
Provider Name (Legal Business Name): MOUNTAIN SMILES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 OCEAN BEACH HWY STE 110
LONGVIEW WA
98632-4081
US

IV. Provider business mailing address

820 OCEAN BEACH HWY STE 110
LONGVIEW WA
98632-4081
US

V. Phone/Fax

Practice location:
  • Phone: 360-577-0566
  • Fax:
Mailing address:
  • Phone: 360-577-0566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code122400000X
TaxonomyDenturist
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ANGEL GIMENEZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 719-300-5933