=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598535189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILE LAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2024
-----------------------------------------------------
Last Update Date | 01/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2431 BLVD LUIS A FERRE STE 202
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-840-0080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2431 BLVD LUIS A FERRE STE 202
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-840-0080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | NATALIA ESTEFANIA LLAURADOR CARABALLO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 787-840-0080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------