=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891152633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILE CONCEPTS ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2016
-----------------------------------------------------
Last Update Date | 01/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 551 N PARK AVE SUITE A
-----------------------------------------------------
City | APOPKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32712-3655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-703-8330
-----------------------------------------------------
Fax | 407-703-8339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 551 N PARK AVE SUITE A
-----------------------------------------------------
City | APOPKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32712-3655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-703-8330
-----------------------------------------------------
Fax | 407-703-8339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KEISHA ALEXANDER
-----------------------------------------------------
Credential | D.D.S., M.S.
-----------------------------------------------------
Telephone | 407-779-0244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN18362
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------