MEDICARE: DENTAL SMILE PROFESSIONALS DAYTON OHIO LLC

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

General Provider Information

NPI Number	:	1336607332
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL SMILE PROFESSIONALS DAYTON OHIO LLC

Provider Business Mailing Address
First Line	:	5221 WAYNETOWNE CT
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-2124
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5221 WAYNETOWNE CT
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-2124
Country	:	US
Telephone Number	:	937-237-0360
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	OPAL ANDERSON
Credential	:
Telephone Number	:	937-237-0360

Provider Enumeration Date	:	03/08/2019
Last Update Date	:	07/20/2022

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