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General NPI Number Information
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NPI Number | 1508453648
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Entity Type | Organization
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Legal Business Name | P&G SMILES LLC
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Dates
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Enumeration Date | 12/23/2020
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Last Update Date | 12/23/2020
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Provider Practice Location Address
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Address Line | 1450 W HORIZON RIDGE PKWY STE B308&309
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City | HENDERSON
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State | NV
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Zip | 89012-4477
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Country | US
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Telephone | 702-703-0102
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Fax | 702-723-6773
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Provider Business Mailing Address
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Address Line | 1450 W HORIZON RIDGE PKWY STE B308&309
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City | HENDERSON
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State | NV
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Zip | 89012-4477
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Country | US
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Telephone | 702-703-0102
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Fax | 702-723-6773
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. PRASHANTI BOLLU
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Credential | DMD, MS, MBA
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Telephone | 617-849-0751
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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