=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750747150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPER SMILES FOR KIDS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2016
-----------------------------------------------------
Last Update Date | 01/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21116 N JOHN WAYNE PKWY STE B7
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85139-2932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-568-1551
-----------------------------------------------------
Fax | 520-423-3912
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21116 N JOHN WAYNE PKWY STE B7
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85139-2932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-568-1551
-----------------------------------------------------
Fax | 520-423-3912
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. MATTHEW ROPER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 520-568-1551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 07288
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------