=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508241993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IAN M. RAE, DMD SMILE INNOVATIONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2015
-----------------------------------------------------
Last Update Date | 07/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5150 CEDAR BROOK CT
-----------------------------------------------------
City | SPRINGBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45066-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-879-1321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5150 CEDAR BROOK CT
-----------------------------------------------------
City | SPRINGBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45066-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-879-1321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IAN M RAE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 937-879-1321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------