MEDICARE: SMILES DENTAL GROUP, PC

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	332BC3200X	Customized Equipment (DME)	D8230	OR

General Provider Information

NPI Number	:	1295149334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILES DENTAL GROUP, PC

Provider Business Mailing Address
First Line	:	820 OCEAN BEACH HWY
Second Line	:	STE 110
City	:	LONGVIEW
State	:	WA
Zip	:	98632-4080
Country	:	US
Telephone Number	:	503-981-1841
Fax Number	:	503-981-7334

Provider Business Practice Location Address
First Line	:	1018 N BOONES FERRY RD
Second Line	:
City	:	WOODBURN
State	:	OR
Zip	:	97071-9602
Country	:	US
Telephone Number	:	503-981-1841
Fax Number	:	503-981-7334

Authorized Official
Title or Position	:	CFO
Name	:	MR. JACOB A LEWIS
Credential	:	CPA, MBA
Telephone Number	:	206-919-6578

Provider Enumeration Date	:	06/17/2014
Last Update Date	:	06/17/2014

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