=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013101419
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST SMILES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2007
-----------------------------------------------------
Last Update Date | 08/29/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2487 S GILBERT RD STE 105
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-732-1888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11512 E QUEENSBOROUGH AVE
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85212-4091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-951-6598
-----------------------------------------------------
Fax | 480-452-1811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | KELLY MARIE POVAR
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 480-951-6598
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 5585
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------