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General NPI Number Information
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NPI Number | 1356518500
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Entity Type | Organization
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Legal Business Name | SMILE SHOPPE
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Dates
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Enumeration Date | 05/15/2008
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Last Update Date | 05/15/2008
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Provider Practice Location Address
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Address Line | 210 S 5TH ST
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City | BURLINGTON
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State | IA
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Zip | 52601-5619
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Country | US
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Telephone | 319-752-1600
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Fax | 319-752-1610
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Provider Business Mailing Address
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Address Line | 210 S 5TH ST
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City | BURLINGTON
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State | IA
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Zip | 52601-5619
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Country | US
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Telephone | 319-752-1600
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Fax | 319-752-1610
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Authorized Official
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Title or Position | PRESIDENT/DENTIST
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Name | DR. AMY REBECCA GROELTZ
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Credential | DDS
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Telephone | 319-752-1600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8298
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License Number State | IA
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