MEDICARE: SMILES LIKE YOURS 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	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1851928949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILES LIKE YOURS LLC

Provider Business Mailing Address
First Line	:	6129 W STONEPATH GARDEN DR
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-3730
Country	:	US
Telephone Number	:	585-230-0035
Fax Number	:

Provider Business Practice Location Address
First Line	:	10431 PATTERSON AVE
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23238-5101
Country	:	US
Telephone Number	:	585-230-0035
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KIARA LESLIE
Credential	:
Telephone Number	:	585-230-0035

Provider Enumeration Date	:	03/26/2020
Last Update Date	:	03/26/2020

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