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General NPI Number Information
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NPI Number | 1356096507
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Entity Type | Organization
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Legal Business Name | SMILE FX
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Dates
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Enumeration Date | 02/16/2022
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Last Update Date | 02/16/2022
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Provider Practice Location Address
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Address Line | 6919 W. FOREST HOME AVE.
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City | MILWAUKEE
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State | WI
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Zip | 53220
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Country | US
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Telephone | 414-545-8226
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Fax | 414-543-4805
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Provider Business Mailing Address
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Address Line | 6919 W. FOREST HOME AVE.
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City | MILWAUKEE
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State | WI
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Zip | 53220
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Country | US
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Telephone | 414-545-8226
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Fax | 414-543-4805
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | GLENN GEQUILLANA
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Credential | DDS
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Telephone | 414-545-8226
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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