MEDICARE: THRIVING 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1972204550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THRIVING SMILES LLC

Provider Business Mailing Address
First Line	:	4526 GLEN EAGLE DR
Second Line	:
City	:	BRECKSVILLE
State	:	OH
Zip	:	44141-2934
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	34155 CENTER RIDGE RD
Second Line	:
City	:	NORTH RIDGEVILLE
State	:	OH
Zip	:	44039-3221
Country	:	US
Telephone Number	:	216-815-1413
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. GEORGE BOUKAS
Credential	:	DMD
Telephone Number	:	216-815-1413

Provider Enumeration Date	:	03/13/2023
Last Update Date	:	03/13/2023

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Directions to “THRIVING SMILES LLC ” Practice Location

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