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General NPI Number Information
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NPI Number | 1164228318
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Entity Type | Organization
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Legal Business Name | MOUNTAIN SMILES, PLLC
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Dates
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Enumeration Date | 02/19/2025
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Last Update Date | 02/27/2025
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Provider Practice Location Address
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Address Line | 820 OCEAN BEACH HWY STE 110
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City | LONGVIEW
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State | WA
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Zip | 98632-4081
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Country | US
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Telephone | 360-577-0566
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Fax |
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Provider Business Mailing Address
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Address Line | 820 OCEAN BEACH HWY STE 110
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City | LONGVIEW
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State | WA
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Zip | 98632-4081
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Country | US
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Telephone | 360-577-0566
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | ANGEL GIMENEZ
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Credential |
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Telephone | 719-300-5933
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0004X
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Taxonomy Name | Dental Anesthesiology
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 126800000X
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Taxonomy Name | Dental Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 122400000X
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Taxonomy Name | Denturist
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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