=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659447688
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY SMILES FAMILY DENTISTRY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 10/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 BOVARD ST
-----------------------------------------------------
City | YERINGTON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-463-1800
-----------------------------------------------------
Fax | 775-463-4810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 BOVARD ST
-----------------------------------------------------
City | YERINGTON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-463-1800
-----------------------------------------------------
Fax | 775-463-4810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. MARLENA E BOOTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-463-1800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4157
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------