=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992010417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILE ENHANCERS DENTAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2010
-----------------------------------------------------
Last Update Date | 08/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6080 S. DURANGO DR. STE 100 SMILE ENHANCERS DENTAL INC.
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-410-9400
-----------------------------------------------------
Fax | 702-410-9402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6080 S. DURANGO DRIVE STE 100
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-410-9400
-----------------------------------------------------
Fax | 702-410-9402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | GLENDA V SANTOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-410-9400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4615
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------