MEDICARE: SMALL SMILES DENTAL CENTER OF WEST COLUMBUS, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1417136870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMALL SMILES DENTAL CENTER OF WEST COLUMBUS, LLC

Provider Business Mailing Address
First Line	:	201 W 8TH ST
Second Line	:	SUITE 810
City	:	PUEBLO
State	:	CO
Zip	:	81003-3038
Country	:	US
Telephone Number	:	719-562-4447
Fax Number	:

Provider Business Practice Location Address
First Line	:	4666 W BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-1611
Country	:	US
Telephone Number	:	614-851-0409
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR, LICENSING & CREDENTIALING
Name	:	MS. TRUDY WILLIAMS
Credential	:
Telephone Number	:	615-750-0342

Provider Enumeration Date	:	11/01/2007
Last Update Date	:	05/17/2010

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