Provider Demographics
NPI:1003254723
Name:SIGNATURE SMILE
Entity Type:Organization
Organization Name:SIGNATURE SMILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:SADRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-767-6453
Mailing Address - Street 1:2247 HELTON DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1035
Mailing Address - Country:US
Mailing Address - Phone:256-767-6453
Mailing Address - Fax:256-764-5370
Practice Address - Street 1:2247 HELTON DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1035
Practice Address - Country:US
Practice Address - Phone:256-767-6453
Practice Address - Fax:256-764-5370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3465122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty