MEDICARE: SMILE STRAIGHT ORTHODONTICS-CENTRAL MS PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1205469111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE STRAIGHT ORTHODONTICS-CENTRAL MS PLLC

Provider Business Mailing Address
First Line	:	5717 E THOMAS RD STE 110
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85251-7620
Country	:	US
Telephone Number	:	623-282-9959
Fax Number	:	602-429-8200

Provider Business Practice Location Address
First Line	:	1189 E COUNTY LINE RD STE 1010
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39211-1836
Country	:	US
Telephone Number	:	601-308-2022
Fax Number	:	601-326-2618

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	TERESA ZWICKY
Credential	:
Telephone Number	:	480-866-8811

Provider Enumeration Date	:	02/19/2020
Last Update Date	:	08/22/2023

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