Provider Demographics
NPI: | 1013598739 |
---|---|
Name: | IMAGINE SMILES PLLC |
Entity Type: | Organization |
Organization Name: | IMAGINE SMILES PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | THAO |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LATHAM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 864-906-6179 |
Mailing Address - Street 1: | 5259 ARIVA DR APT 101 |
Mailing Address - Street 2: | |
Mailing Address - City: | LAKELAND |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33812-4436 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 864-906-6179 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 13205 REAMS RD UNIT 164 |
Practice Address - Street 2: | |
Practice Address - City: | WINDERMERE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 34786 |
Practice Address - Country: | US |
Practice Address - Phone: | 864-906-6179 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-04-15 |
Last Update Date: | 2021-04-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223P0221X | Dental Providers | Dentist | Pediatric Dentistry | Group - Multi-Specialty |
No | 1223X0400X | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | Group - Multi-Specialty |