MEDICARE: THE SMILE SPA

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	7481	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487941860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SMILE SPA

Provider Business Mailing Address
First Line	:	8110 CORDOVA RD
Second Line	:	SUITE 125
City	:	CORDOVA
State	:	TN
Zip	:	38016-0520
Country	:	US
Telephone Number	:	901-755-0001
Fax Number	:	901-755-9679

Provider Business Practice Location Address
First Line	:	8110 CORDOVA RD
Second Line	:	SUITE 125
City	:	CORDOVA
State	:	TN
Zip	:	38016-0520
Country	:	US
Telephone Number	:	901-755-0001
Fax Number	:	901-755-9679

Authorized Official
Title or Position	:	DOCTOR
Name	:	ANDREA M HENRY
Credential	:	DDS
Telephone Number	:	901-755-0001

Provider Enumeration Date	:	07/06/2011
Last Update Date	:	07/06/2011

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Directions to “THE SMILE SPA ” Practice Location

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