=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568803203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILES 4 KIDS HAILEY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2013
-----------------------------------------------------
Last Update Date | 07/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 S RIVER ST
-----------------------------------------------------
City | HAILEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83333-8426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-731-8726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 317 S RIVER ST
-----------------------------------------------------
City | HAILEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83333-8426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-731-8726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | RHONDA ELQUIST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-760-0335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------