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General NPI Number Information
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NPI Number | 1467820068
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Entity Type | Organization
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Legal Business Name | YOUR SPECIAL SMILES PLLC
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Dates
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Enumeration Date | 09/14/2015
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Last Update Date | 09/14/2015
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Provider Practice Location Address
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Address Line | 905 SHOSHONE ST N
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City | TWIN FALLS
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State | ID
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Zip | 83301-6363
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Country | US
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Telephone | 208-859-8449
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 195
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City | JEROME
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State | ID
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Zip | 83338-0195
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Country | US
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Telephone | 208-859-8449
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BROOKE MARIE-OSGOOD FUKUOKA
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Credential | DMD
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Telephone | 208-859-8449
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 4533
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License Number State | ID
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