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General NPI Number Information
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NPI Number | 1861720245
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Entity Type | Organization
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Legal Business Name | HEALTHY SMILES, INC.
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Dates
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Enumeration Date | 11/24/2009
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Last Update Date | 11/24/2009
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Provider Practice Location Address
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Address Line | 63407 130TH AVE
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City | CLAREMONT
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State | MN
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Zip | 55924-4656
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Country | US
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Telephone | 507-319-6845
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Fax |
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Provider Business Mailing Address
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Address Line | 63407 130TH AVE
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City | CLAREMONT
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State | MN
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Zip | 55924-4656
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Country | US
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Telephone | 507-319-6845
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | SHANNON MARIE KRUCKEBERG
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Credential | RDH
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Telephone | 507-319-6845
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number |
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License Number State |
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