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General NPI Number Information
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NPI Number | 1578792628
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Entity Type | Organization
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Legal Business Name | SUPERB SMILES
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Dates
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Enumeration Date | 07/10/2009
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Last Update Date | 07/10/2009
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Provider Practice Location Address
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Address Line | 200 CONRAD HARCOURT WAY
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City | RUSHVILLE
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State | IN
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Zip | 46173-1100
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Country | US
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Telephone | 765-932-5533
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Fax | 765-932-4569
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Provider Business Mailing Address
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Address Line | 200 CONRAD HARCOURT WAY
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City | RUSHVILLE
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State | IN
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Zip | 46173-1100
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Country | US
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Telephone | 765-932-5533
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Fax | 765-932-4569
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | RON L. WINTERS
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Credential | D.D.S.
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Telephone | 765-932-5533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12008162
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License Number State | IN
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