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General NPI Number Information
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NPI Number | 1083152243
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Entity Type | Organization
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Legal Business Name | CREATING SMILES LLC
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Dates
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Enumeration Date | 02/08/2017
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Last Update Date | 02/08/2017
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Provider Practice Location Address
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Address Line | 101 UNITED DR SUITE 150
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City | COLLINSVILLE
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State | IL
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Zip | 62234-7428
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Country | US
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Telephone | 618-345-7676
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Fax | 618-345-7603
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Provider Business Mailing Address
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Address Line | 101 UNITED DR SUITE 150
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City | COLLINSVILLE
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State | IL
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Zip | 62234-7428
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Country | US
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Telephone | 618-345-7676
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Fax | 618-345-7603
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Authorized Official
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Title or Position | DENTIST/ OWNER
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Name | DR. GENA FARRIS PINEDA
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Credential | DDS
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Telephone | 618-345-7676
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 019026456
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License Number State | IL
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