MEDICARE: GLOWING SMILES 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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1811652282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLOWING SMILES LLC

Provider Business Mailing Address
First Line	:	1701 N GREEN VALLEY PKWY STE 5E
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89074-5889
Country	:	US
Telephone Number	:	702-576-1709
Fax Number	:	702-364-8134

Provider Business Practice Location Address
First Line	:	1701 N GREEN VALLEY PKWY STE 5E
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89074-5889
Country	:	US
Telephone Number	:	702-576-1709
Fax Number	:	702-364-8134

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KARLA BROWN
Credential	:
Telephone Number	:	702-576-1709

Provider Enumeration Date	:	11/01/2021
Last Update Date	:	11/08/2021

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Directions to “GLOWING SMILES LLC ” Practice Location

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