MEDICARE: SMILE GALAXY PEDIATRIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	5436	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1390128	OTHER		UNITED CONCORDIA

General Provider Information

NPI Number	:	1023034451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE GALAXY PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	PO BOX 892290
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73189-2290
Country	:	US
Telephone Number	:	405-692-1222
Fax Number	:	405-703-0930

Provider Business Practice Location Address
First Line	:	9801 S. PENNSYLVANIA
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6925
Country	:	US
Telephone Number	:	405-692-1222
Fax Number	:	405-703-0930

Authorized Official
Title or Position	:	BUSINESS OWNER
Name	:	MR. ROBERT BRIAN MOLLOY
Credential	:	D.D.S.
Telephone Number	:	405-692-1222

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	11/07/2012

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Directions to “SMILE GALAXY PEDIATRIC DENTISTRY ” Practice Location

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