=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588963615
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUTURE SMILES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2011
-----------------------------------------------------
Last Update Date | 03/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3074 ARVILLE ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-7490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-889-3763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3074 ARVILLE ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-7490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-889-3763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. MARY TERESA CHANDLER
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 702-889-3763
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 3419
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 3636
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 3626
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 10099
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 101718
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 2713
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 4380
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 4447
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 3646
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 3420
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------