=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700312907
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AESTHETIC SMILES P LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2017
-----------------------------------------------------
Last Update Date | 05/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2015 N LOCUST GROVE RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-1827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-888-1802
-----------------------------------------------------
Fax | 208-887-3908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2015 N LOCUST GROVE RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-1827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-888-1802
-----------------------------------------------------
Fax | 208-887-3908
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | TERESA LECHUGA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-888-1802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D4225
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------