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General NPI Number Information
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NPI Number | 1447664404
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Entity Type | Organization
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Legal Business Name | GROWING SMILES PEDIATRIC DENTISTRY PC
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Dates
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Enumeration Date | 06/18/2014
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Last Update Date | 06/18/2014
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Provider Practice Location Address
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Address Line | 1111 CUMBERLAND XING
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City | VALPARAISO
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State | IN
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Zip | 46383-2356
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Country | US
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Telephone | 219-286-6148
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Fax | 219-286-6149
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Provider Business Mailing Address
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Address Line | 1111 CUMBERLAND XING
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City | VALPARAISO
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State | IN
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Zip | 46383-2356
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Country | US
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Telephone | 219-286-6148
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Fax | 219-286-6149
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CARISSE M CORNS
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Credential | D.D.S
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Telephone | 213-500-6789
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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 | 12011775A
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License Number State | IN
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