=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720565690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYESMILE DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2018
-----------------------------------------------------
Last Update Date | 07/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 MAIN ST STE B
-----------------------------------------------------
City | HAYS
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67601-3658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-899-3279
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1604 W 29TH ST
-----------------------------------------------------
City | HAYS
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67601-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-899-3279
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JARROD E JONES
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 713-899-3279
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------