=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730650508
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUICK SMILES LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2018
-----------------------------------------------------
Last Update Date | 12/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2268 E WILLIAMS FIELD RD STE 118
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-0756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-757-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2530 E GERMANN RD STE 25
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85286-1406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | JAKE WRIGHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-757-0000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------