=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700044625
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILES4KIDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2008
-----------------------------------------------------
Last Update Date | 05/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 OXBOW DR UNIT 360-A
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81401-4781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-249-8595
-----------------------------------------------------
Fax | 970-249-5903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 OXBOW DR UNIT 360-A
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81401-4781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-249-8595
-----------------------------------------------------
Fax | 970-249-5903
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. MARY ISABELL HOLYBEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-249-8595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8632
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------