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General NPI Number Information
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NPI Number | 1295920346
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Entity Type | Organization
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Legal Business Name | WILD SMILES, LLC
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Dates
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Enumeration Date | 09/12/2007
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Last Update Date | 12/16/2010
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Provider Practice Location Address
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Address Line | 203 NORTH LAKE DRIVE
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City | LEXINGTON
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State | SC
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Zip | 29072
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Country | US
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Telephone | 803-356-1606
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Fax | 803-359-7542
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Provider Business Mailing Address
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Address Line | 203 NORTH LAKE DRIVE
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City | LEXINGTON
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State | SC
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Zip | 29072
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Country | US
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Telephone | 803-356-1606
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Fax | 803-359-7542
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Authorized Official
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Title or Position | INSURANCE COORDINATOR
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Name | MRS. DONNA M. BABCOCK
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Credential |
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Telephone | 803-356-1606
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 3351
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | SC3351
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License Number State | SC
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