Provider Demographics
NPI:1003276007
Name:DESIGNER SMILES PA
Entity Type:Organization
Organization Name:DESIGNER SMILES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:OSPINA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:407-894-3571
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:OSTEEN
Mailing Address - State:FL
Mailing Address - Zip Code:32764-0030
Mailing Address - Country:US
Mailing Address - Phone:407-894-3571
Mailing Address - Fax:407-895-5511
Practice Address - Street 1:5030 SR 46 STE 108
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-9247
Practice Address - Country:US
Practice Address - Phone:407-894-3571
Practice Address - Fax:407-895-5511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL122300000X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1255352142Medicaid