Healthcare Provider Details

I. General information

NPI: 1063539963
Provider Name (Legal Business Name): RJ SMILES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 WEST BROADWAY AVE SUITE 106
JACKSON WY
83001
US

IV. Provider business mailing address

P.O. BOX 9340
JACKSON WY
83002-9340
US

V. Phone/Fax

Practice location:
  • Phone: 307-732-2273
  • Fax: 307-732-1660
Mailing address:
  • Phone: 307-732-2273
  • Fax: 307-732-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: PAULA J RIDGEWAY
Title or Position: MANAGING PARTNER
Credential: DDS
Phone: 307-732-2273