=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720338668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY SMILES FAMILY DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2012
-----------------------------------------------------
Last Update Date | 08/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4392 LIBERTY RD S
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97302-6171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-315-2500
-----------------------------------------------------
Fax | 503-339-1981
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4392 LIBERTY RD S
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97302-6171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-315-2500
-----------------------------------------------------
Fax | 503-339-1981
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DDS
-----------------------------------------------------
Name | DR. NA XU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-315-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | D8941
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------