=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821455437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILE DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2016
-----------------------------------------------------
Last Update Date | 01/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10238 E HAMPTON AVE STE 105
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85209-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-986-2600
-----------------------------------------------------
Fax | 480-689-4164
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10238 E HAMPTON AVE STE 105
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85209-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-986-2600
-----------------------------------------------------
Fax | 480-689-4164
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR.
-----------------------------------------------------
Name | MIKE LEE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 480-986-2600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------