=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619237633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUTREACH FOR SMILES OF COLORADO, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2012
-----------------------------------------------------
Last Update Date | 05/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8519 COLLINGWOOD
-----------------------------------------------------
City | UNIVERSAL CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78148-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-412-5798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8519 COLLINGWOOD
-----------------------------------------------------
City | UNIVERSAL CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78148-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-412-5798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LORRAINE SAN MIGUEL
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 210-412-5798
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 906556
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------