MEDICARE: HEALTHY SMILES FOR KIDS OF ORANGE COUNTY

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	1223P0221X	Pediatric Dentistry	550000106	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G94040-01	OTHER	CA	MEDI-CAL
2	G94040-01	OTHER	CA	DENTI-CAL

General Provider Information

NPI Number	:	1720292949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHY SMILES FOR KIDS OF ORANGE COUNTY

Provider Business Mailing Address
First Line	:	10602 CHAPMAN AVE
Second Line	:	SUITE 200
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-3103
Country	:	US
Telephone Number	:	714-537-0700
Fax Number	:	714-537-0733

Provider Business Practice Location Address
First Line	:	10602 CHAPMAN AVE
Second Line	:	SUITE 200
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-3103
Country	:	US
Telephone Number	:	714-537-0700
Fax Number	:	714-537-0733

Authorized Official
Title or Position	:	CEO
Name	:	MRS. ELIZABETH A BEAR
Credential	:	RN, JD
Telephone Number	:	714-537-0700

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	12/14/2009

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