Provider Demographics
NPI:1023034451
Name:SMILE GALAXY PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SMILE GALAXY PEDIATRIC DENTISTRY
Other - Org Name:SMILE ZONE PEDIATRIC DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:MOLLOY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-692-1222
Mailing Address - Street 1:PO BOX 892290
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73189-2290
Mailing Address - Country:US
Mailing Address - Phone:405-692-1222
Mailing Address - Fax:405-703-0930
Practice Address - Street 1:9801 S. PENNSYLVANIA
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6925
Practice Address - Country:US
Practice Address - Phone:405-692-1222
Practice Address - Fax:405-703-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5436261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200066610AMedicaid
1390128OtherUNITED CONCORDIA