MEDICARE: SMILE TWO PROFESSIONALS

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	:	1336373109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE TWO PROFESSIONALS

Provider Business Mailing Address
First Line	:	3952 N ACADEMY BLVD STE A
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-5910
Country	:	US
Telephone Number	:	719-622-1225
Fax Number	:	719-591-2032

Provider Business Practice Location Address
First Line	:	3952 N ACADEMY BLVD STE A
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-5910
Country	:	US
Telephone Number	:	719-622-1225
Fax Number	:	719-591-2032

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TANIA QUINN
Credential	:	DMD
Telephone Number	:	719-622-1225

Provider Enumeration Date	:	05/08/2009
Last Update Date	:	05/08/2009

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