MEDICARE: SMILE INNOVATIONS DENTISTRY CORP

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	:	1578312302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE INNOVATIONS DENTISTRY CORP

Provider Business Mailing Address
First Line	:	3833 CLEVELAND AVE STE 170
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8663
Country	:	US
Telephone Number	:	239-935-7704
Fax Number	:	239-935-7709

Provider Business Practice Location Address
First Line	:	3833 CLEVELAND AVE STE 170
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8663
Country	:	US
Telephone Number	:	239-935-7704
Fax Number	:	239-935-7709

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. YAMILE VILLAVICENCIO
Credential	:	DDS
Telephone Number	:	239-233-4531

Provider Enumeration Date	:	05/14/2024
Last Update Date	:	05/21/2024

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