=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194138917
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILEVILLE DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2014
-----------------------------------------------------
Last Update Date | 06/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2234 NATIVE WOODS LN STE 101
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544-6980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-994-4777
-----------------------------------------------------
Fax | 877-596-5014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2234 NATIVE WOODS LN STE 101
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544-6980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-994-4777
-----------------------------------------------------
Fax | 877-596-5014
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KAREN E MEJIAS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 813-994-4777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN18930
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------