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General NPI Number Information
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NPI Number | 1588995229
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Entity Type | Organization
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Legal Business Name | CREATE-A-SMILE, PC
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Dates
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Enumeration Date | 01/20/2010
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Last Update Date | 05/17/2022
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Provider Practice Location Address
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Address Line | 2815 N WALNUT ST
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City | BLOOMINGTON
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State | IN
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Zip | 47404-2077
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Country | US
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Telephone | 812-332-1405
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Fax | 812-332-4331
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Provider Business Mailing Address
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Address Line | 2815 N WALNUT ST
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City | BLOOMINGTON
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State | IN
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Zip | 47404-2077
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Country | US
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Telephone | 812-332-1405
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Fax | 812-332-4331
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Authorized Official
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Title or Position | OWNER
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Name | DR. SHANNON KENNETH MOORE
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Credential | DMD, MSED
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Telephone | 812-332-1405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12011246A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12010311A
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License Number State | IN
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