=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528015328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILES ON MAIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2006
-----------------------------------------------------
Last Update Date | 01/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 SOUTH MAIN STE 1
-----------------------------------------------------
City | MAQUOKETA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-652-4133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 SOUTH MAIN STE 1
-----------------------------------------------------
City | MAQUOKETA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-652-4133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SALVADOR D ATIENZA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 563-652-4133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8368
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 7745
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------